Provider Demographics
NPI:1811775216
Name:CSRA PSYCHOLOGICAL SERVICES LIMITED LIABILITY COMPANY
Entity type:Organization
Organization Name:CSRA PSYCHOLOGICAL SERVICES LIMITED LIABILITY COMPANY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ELIZABETH
Authorized Official - Middle Name:L
Authorized Official - Last Name:EDWARDS
Authorized Official - Suffix:
Authorized Official - Credentials:LPC
Authorized Official - Phone:706-814-6429
Mailing Address - Street 1:125 COMMERCIAL BLVD PO BOX 204301
Mailing Address - Street 2:
Mailing Address - City:MARTINEZ
Mailing Address - State:GA
Mailing Address - Zip Code:30917-4301
Mailing Address - Country:US
Mailing Address - Phone:706-814-6429
Mailing Address - Fax:706-814-6429
Practice Address - Street 1:930 GLENHAVEN DR
Practice Address - Street 2:
Practice Address - City:EVANS
Practice Address - State:GA
Practice Address - Zip Code:30809-0445
Practice Address - Country:US
Practice Address - Phone:706-814-6429
Practice Address - Fax:706-814-6429
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-09-18
Last Update Date:2023-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)