Provider Demographics
NPI:1104960715
Name:ROLAND, MARK MANFRED (PHD)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:MANFRED
Last Name:ROLAND
Suffix:
Gender:M
Credentials:PHD
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Mailing Address - Street 1:PO BOX 515
Mailing Address - Street 2:PSYCHOLOGICAL CONSULTANTS OF MARIETTA PC
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30061-0515
Mailing Address - Country:US
Mailing Address - Phone:770-420-9448
Mailing Address - Fax:770-420-9441
Practice Address - Street 1:21 TRAMMEL ST. SW
Practice Address - Street 2:PSYCHOLOGICAL CONSULTANTS OF MARIETTA PC
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30064-3249
Practice Address - Country:US
Practice Address - Phone:770-420-9448
Practice Address - Fax:770-420-9441
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-16
Last Update Date:2008-09-16
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Provider Licenses
StateLicense IDTaxonomies
GA1872103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00661691AMedicaid
GA00661691AMedicaid
GA68BBFZVMedicare PIN