Healthcare Provider Details

I. General information

NPI: 1922286731
Provider Name (Legal Business Name): PSYCHOLOGICAL SERVICES OF ATLANTA, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/04/2008
Last Update Date: 02/04/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1770 OLD SPRING HOUSE LN SUITE #114
ATLANTA GA
30338-6213
US

IV. Provider business mailing address

1770 OLD SPRING HOUSE LN SUITE #114
ATLANTA GA
30338-6213
US

V. Phone/Fax

Practice location:
  • Phone: 770-452-5353
  • Fax: 770-452-5363
Mailing address:
  • Phone: 770-452-5353
  • Fax: 770-452-5363

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPSY002970
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code103TC2200X
TaxonomyClinical Child & Adolescent Psychologist
License NumberPSY002970
License Number StateGA
# 3
Primary TaxonomyN
Taxonomy Code103TF0000X
TaxonomyFamily Psychologist
License NumberPSY002970
License Number StateGA
# 4
Primary TaxonomyN
Taxonomy Code103TP2701X
TaxonomyGroup Psychotherapy Psychologist
License NumberPSY002970
License Number StateGA

VIII. Authorized Official

Name: DR. DAYNA M DIAZ
Title or Position: LICENSED PSYCHOLOGIST
Credential: PH.D.
Phone: 770-452-5353