Provider Demographics
NPI:1396277968
Name:PSYCHIATRIC PROFESSIONALS OF GEORGIA, LLC
Entity type:Organization
Organization Name:PSYCHIATRIC PROFESSIONALS OF GEORGIA, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROVIDER ENROLLMENT ASSOCIATE
Authorized Official - Prefix:
Authorized Official - First Name:KALEY
Authorized Official - Middle Name:
Authorized Official - Last Name:DAVIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:470-857-4412
Mailing Address - Street 1:1325 SATELLITE BLVD NW BLDG 400
Mailing Address - Street 2:
Mailing Address - City:SUWANEE
Mailing Address - State:GA
Mailing Address - Zip Code:30024-4651
Mailing Address - Country:US
Mailing Address - Phone:678-263-3080
Mailing Address - Fax:678-496-9863
Practice Address - Street 1:1325 SATELLITE BLVD NW BLDG 400
Practice Address - Street 2:
Practice Address - City:SUWANEE
Practice Address - State:GA
Practice Address - Zip Code:30024-4651
Practice Address - Country:US
Practice Address - Phone:678-263-3080
Practice Address - Fax:678-496-9863
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-04-01
Last Update Date:2025-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA582972084A0401X
GA590162084P0804X
GA0603252084P0804X
GA555632084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Multi-Specialty
No2084A0401XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyAddiction MedicineGroup - Multi-Specialty
No2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent PsychiatryGroup - Multi-Specialty