Healthcare Provider Details

I. General information

NPI: 1558320572
Provider Name (Legal Business Name): SOUTH GEORGIA NEUROPSYCHOLOGICAL ASSOCIATES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/20/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1211 PALMYRA RD
ALBANY GA
31701-1935
US

IV. Provider business mailing address

1211 PALMYRA RD
ALBANY GA
31701-1935
US

V. Phone/Fax

Practice location:
  • Phone: 229-439-8686
  • Fax: 229-883-4484
Mailing address:
  • Phone: 229-439-8686
  • Fax: 229-883-4484

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103G00000X
TaxonomyClinical Neuropsychologist
License NumberPSY002280
License Number StateGA

VIII. Authorized Official

Name: DR. TODD S SMITH
Title or Position: CLINICAL NEUROPSYCHOLOGICAL
Credential: PSY.D
Phone: 229-439-8686