Provider Demographics
NPI:1285805754
Name:DIANE C. SPERRY, PH.D., LLC
Entity type:Organization
Organization Name:DIANE C. SPERRY, PH.D., LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:REGISTERED AGENT
Authorized Official - Prefix:
Authorized Official - First Name:DIANE
Authorized Official - Middle Name:C
Authorized Official - Last Name:SPERRY
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:678-935-9567
Mailing Address - Street 1:10475 MEDLOCK BRIDGE RD
Mailing Address - Street 2:BUILDING 300, SUITE 315
Mailing Address - City:JOHNS CREEK
Mailing Address - State:GA
Mailing Address - Zip Code:30097-4433
Mailing Address - Country:US
Mailing Address - Phone:678-935-9567
Mailing Address - Fax:678-935-9568
Practice Address - Street 1:10475 MEDLOCK BRIDGE RD
Practice Address - Street 2:BUILDING 300, SUITE 315
Practice Address - City:JOHNS CREEK
Practice Address - State:GA
Practice Address - Zip Code:30097-4433
Practice Address - Country:US
Practice Address - Phone:678-935-9567
Practice Address - Fax:678-935-9568
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-12
Last Update Date:2008-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPSY003160261QM0850X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health