Provider Demographics
NPI:1487986493
Name:CHATTAHOOCHEE CHILD PSYCHOLOGY
Entity type:Organization
Organization Name:CHATTAHOOCHEE CHILD PSYCHOLOGY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PSYCHOLOGIST
Authorized Official - Prefix:DR
Authorized Official - First Name:KRISTEN
Authorized Official - Middle Name:W
Authorized Official - Last Name:GREEN
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:678-971-5355
Mailing Address - Street 1:430 PRIOR STREET NE
Mailing Address - Street 2:
Mailing Address - City:GAINESVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30501
Mailing Address - Country:US
Mailing Address - Phone:678-971-5355
Mailing Address - Fax:678-971-5359
Practice Address - Street 1:430 PRIOR STREET NE
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:GA
Practice Address - Zip Code:30501
Practice Address - Country:US
Practice Address - Phone:678-971-5355
Practice Address - Fax:678-971-5359
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-02-02
Last Update Date:2012-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA3114103TC2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & AdolescentGroup - Single Specialty