Healthcare Provider Details

I. General information

NPI: 1295798486
Provider Name (Legal Business Name): NICK A DEFILIPPIS PH.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/09/2006
Last Update Date: 12/12/2020
Certification Date: 12/12/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

990 HAMMOND DR NE SUITE 730
ATLANTA GA
30328-5529
US

IV. Provider business mailing address

990 HAMMOND DR STE 575
ATLANTA GA
30328-9113
US

V. Phone/Fax

Practice location:
  • Phone: 770-730-9930
  • Fax: 770-730-0998
Mailing address:
  • Phone: 770-730-9930
  • Fax: 770-730-0998

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TA0400X
TaxonomyAddiction (Substance Use Disorder) Psychologist
License Number536
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code103G00000X
TaxonomyClinical Neuropsychologist
License Number536
License Number StateGA
# 3
Primary TaxonomyN
Taxonomy Code103TF0200X
TaxonomyForensic Psychologist
License Number536
License Number StateGA
# 4
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number536
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: