1578832143 NPI number — PSYCHOTHERAPY AND TRAUMA SPECIALISTS

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1578832143 NPI number — PSYCHOTHERAPY AND TRAUMA SPECIALISTS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PSYCHOTHERAPY AND TRAUMA SPECIALISTS
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1578832143
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/27/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
500 LANIER AVE W
Provider Second Line Business Mailing Address:
SUITE 913
Provider Business Mailing Address City Name:
FAYETTEVILLE
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30214-7636
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
770-719-8858
Provider Business Mailing Address Fax Number:
770-719-8856

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
500 LANIER AVE W
Provider Second Line Business Practice Location Address:
SUITE 913
Provider Business Practice Location Address City Name:
FAYETTEVILLE
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30214-7636
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
770-719-8858
Provider Business Practice Location Address Fax Number:
770-719-8856
Provider Enumeration Date:
12/27/2011

Additional Information

Authorized Official

Authorized Official Last Name:
BREHM
Authorized Official First Name:
DEBORAH
Authorized Official Middle Name:
L
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
770-719-8858

Provider Taxonomy Codes

  • Taxonomy code: 251S00000X , with the licence number:  LPC006470 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 251S00000X , with the licence number: LPC004328 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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