1790992360 NPI number — PSYCHOLOGICAL SERVICES OF COASTAL GEORGIA, PC

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 1790992360 NPI number — PSYCHOLOGICAL SERVICES OF COASTAL GEORGIA, PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PSYCHOLOGICAL SERVICES OF COASTAL GEORGIA, PC
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:
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:
1790992360
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/10/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 970
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
RICHMOND HILL
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
31324-0970
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
912-756-5696
Provider Business Mailing Address Fax Number:
912-756-5636

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
10375 FORD AVE STE 2
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
RICHMOND HILL
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
31324-8811
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
912-756-5696
Provider Business Practice Location Address Fax Number:
912-756-5636
Provider Enumeration Date:
05/16/2007

Additional Information

Authorized Official

Authorized Official Last Name:
RICHARDSON
Authorized Official First Name:
BRENDA
Authorized Official Middle Name:
SUE
Authorized Official Title or Position:
PSYCHOLOGIST
Authorized Official Telephone Number:
912-756-5696

Provider Taxonomy Codes

  • Taxonomy code: 103T00000X , with the licence number:  0931 , 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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