Healthcare Provider Details

I. General information

NPI: 1588932503
Provider Name (Legal Business Name): COLUMBUS STATE UNIVERSITY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/05/2011
Last Update Date: 12/05/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4225 UNIVERSITY AVE SCHUSTER CENTER
COLUMBUS GA
31907-5679
US

IV. Provider business mailing address

PO BOX 168007
IRVING TX
75016-8007
US

V. Phone/Fax

Practice location:
  • Phone: 706-507-8740
  • Fax: 706-507-8753
Mailing address:
  • Phone: 469-735-4555
  • Fax: 469-735-4640

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License Number
License Number State

VIII. Authorized Official

Name: MS. LISA J BROWN
Title or Position: CREDENTIALING DIRECTOR
Credential: CPMSM
Phone: 469-735-4555