Provider Demographics
NPI:1285787275
Name:HILL, CONNIE DESSONVILLE (PHD)
Entity type:Individual
Prefix:DR
First Name:CONNIE
Middle Name:DESSONVILLE
Last Name:HILL
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:125 CHURCH ST NE
Mailing Address - Street 2:SUITE 210
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30060-8638
Mailing Address - Country:US
Mailing Address - Phone:770-428-7395
Mailing Address - Fax:770-428-1964
Practice Address - Street 1:125 CHURCH ST NE
Practice Address - Street 2:SUITE 210
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30060-8638
Practice Address - Country:US
Practice Address - Phone:770-428-7395
Practice Address - Fax:770-428-1964
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPSY000963103G00000X, 103TA0700X, 103TC0700X, 103T00000X
103T00000X, 103TH0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
Not Answered103T00000XBehavioral Health & Social Service ProvidersPsychologist
Not Answered103TA0700XBehavioral Health & Social Service ProvidersPsychologistAdult Development & Aging
Not Answered103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Not Answered103TH0100XBehavioral Health & Social Service ProvidersPsychologistHealth Service
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAR74734Medicare UPIN
GA68BBCKDMedicare ID - Type Unspecified