Healthcare Provider Details

I. General information

NPI: 1508648403
Provider Name (Legal Business Name): DONE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/17/2023
Last Update Date: 11/08/2023
Certification Date: 10/30/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1201 W PEACHTREE ST NW STE 2300
ATLANTA GA
30309-3453
US

IV. Provider business mailing address

1201 W PEACHTREE ST NW STE 2300
ATLANTA GA
30309-3453
US

V. Phone/Fax

Practice location:
  • Phone: 415-735-5804
  • Fax:
Mailing address:
  • Phone: 415-735-5804
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number
License Number State

VIII. Authorized Official

Name: CREDENTIALING DEPARTMENT
Title or Position: OFFICE MANAGER/BUSINESS STAFF CONTA
Credential:
Phone: 415-671-2165