MEDICARE: PSYCHOLOGICAL SERVICES OF ATLANTA, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103TC2200X	Clinical Child & Adolescent Psychologist	PSY002970	GA
2	103TF0000X	Family Psychologist	PSY002970	GA
3	103TP2701X	Group Psychotherapy Psychologist	PSY002970	GA
4	103TC0700X	Clinical Psychologist	PSY002970	GA

General Provider Information

NPI Number	:	1922286731
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PSYCHOLOGICAL SERVICES OF ATLANTA, LLC

Provider Business Mailing Address
First Line	:	1770 OLD SPRING HOUSE LN
Second Line	:	SUITE #114
City	:	ATLANTA
State	:	GA
Zip	:	30338-6213
Country	:	US
Telephone Number	:	770-452-5353
Fax Number	:	770-452-5363

Provider Business Practice Location Address
First Line	:	1770 OLD SPRING HOUSE LN
Second Line	:	SUITE #114
City	:	ATLANTA
State	:	GA
Zip	:	30338-6213
Country	:	US
Telephone Number	:	770-452-5353
Fax Number	:	770-452-5363

Authorized Official
Title or Position	:	LICENSED PSYCHOLOGIST
Name	:	DR. DAYNA M DIAZ
Credential	:	PH.D.
Telephone Number	:	770-452-5353

Provider Enumeration Date	:	02/04/2008
Last Update Date	:	02/04/2008

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