Healthcare Provider Details

I. General information

NPI: 1104849215
Provider Name (Legal Business Name): LARRY E DANIELS PSY.D
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/26/2006
Last Update Date: 12/01/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2301 WRIGHTSBORO RD
AUGUSTA GA
30904-6219
US

IV. Provider business mailing address

2301 WRIGHTSBORO RD
AUGUSTA GA
30904-6219
US

V. Phone/Fax

Practice location:
  • Phone: 706-733-7029
  • Fax: 706-733-1376
Mailing address:
  • Phone: 706-733-7029
  • Fax: 706-733-1376

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number831
License Number StateSC
# 2
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License NumberPSY002223
License Number StateGA
# 3
Primary TaxonomyN
Taxonomy Code103TB0200X
TaxonomyCognitive & Behavioral Psychologist
License NumberPSY002223
License Number StateGA
# 4
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPSY002223
License Number StateGA
# 5
Primary TaxonomyN
Taxonomy Code103TF0000X
TaxonomyFamily Psychologist
License NumberPSY002223
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: