Provider Demographics
NPI:1104255959
Name:GEORGIA PEDIATRIC PSYCHOLOGY, INC.
Entity type:Organization
Organization Name:GEORGIA PEDIATRIC PSYCHOLOGY, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CO-OWNER/CLINICAL PSYCHOLOGIST
Authorized Official - Prefix:
Authorized Official - First Name:AVITAL
Authorized Official - Middle Name:K
Authorized Official - Last Name:COHEN
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD
Authorized Official - Phone:678-999-3477
Mailing Address - Street 1:750 HAMMOND DR
Mailing Address - Street 2:BLDG 1, STE 100
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30328-5532
Mailing Address - Country:US
Mailing Address - Phone:678-999-3477
Mailing Address - Fax:678-999-3567
Practice Address - Street 1:750 HAMMOND DR
Practice Address - Street 2:BLDG 1, STE 100
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30328-5532
Practice Address - Country:US
Practice Address - Phone:678-999-3477
Practice Address - Fax:678-999-3567
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-11-02
Last Update Date:2013-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA3672103TC0700X
GA2999103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty