Provider Demographics
NPI:1528289436
Name:RALSTON, MADINAH IKHLAS (PHD)
Entity type:Individual
Prefix:DR
First Name:MADINAH
Middle Name:IKHLAS
Last Name:RALSTON
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:7059 RED MAPLE LN
Mailing Address - Street 2:
Mailing Address - City:LITHONIA
Mailing Address - State:GA
Mailing Address - Zip Code:30058-2998
Mailing Address - Country:US
Mailing Address - Phone:404-432-5259
Mailing Address - Fax:770-482-7868
Practice Address - Street 1:1631 PHOENIX BLVD
Practice Address - Street 2:SUITE 5
Practice Address - City:COLLEGE PARK
Practice Address - State:GA
Practice Address - Zip Code:30349-5545
Practice Address - Country:US
Practice Address - Phone:770-909-6550
Practice Address - Fax:770-909-6551
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
GAPSY003079103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical