Provider Demographics
NPI:1962543579
Name:WEST GEORGIA PSYCHOLOGICAL SERVICES
Entity type:Organization
Organization Name:WEST GEORGIA PSYCHOLOGICAL SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PSYCHOLOGIST
Authorized Official - Prefix:DR
Authorized Official - First Name:TINA
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:CAUDILL
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD
Authorized Official - Phone:678-232-9078
Mailing Address - Street 1:PO BOX 1916
Mailing Address - Street 2:
Mailing Address - City:DOUGLASVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30133-1916
Mailing Address - Country:US
Mailing Address - Phone:678-232-9078
Mailing Address - Fax:866-489-2642
Practice Address - Street 1:6264 HOSPITAL WAY
Practice Address - Street 2:
Practice Address - City:DOUGLASVILLE
Practice Address - State:GA
Practice Address - Zip Code:30134-1944
Practice Address - Country:US
Practice Address - Phone:678-232-9078
Practice Address - Fax:866-489-2642
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-08
Last Update Date:2012-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA002899103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA112025855CMedicaid
GA10071390OtherAMERIGROUP
GA112025855EMedicaid
GA112025855DMedicaid
GA112025855FMedicaid