Healthcare Provider Details

I. General information

NPI: 1649609751
Provider Name (Legal Business Name): JOANNA T. KOULIANOS, PH. D., INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/08/2013
Last Update Date: 11/08/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

22 N FLORIDA ST
MOBILE AL
36607-3108
US

IV. Provider business mailing address

22 N FLORIDA ST
MOBILE AL
36607-3108
US

V. Phone/Fax

Practice location:
  • Phone: 251-300-2743
  • Fax:
Mailing address:
  • Phone: 251-300-2743
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number1453
License Number StateAL

VIII. Authorized Official

Name: JOANNA T KOULIANOS
Title or Position: PSYCHOLOGIST
Credential: PH D
Phone: 251-300-2743