Healthcare Provider Details

I. General information

NPI: 1780070664
Provider Name (Legal Business Name): DANIEL OLIVER FRY BA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/08/2015
Last Update Date: 04/08/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

700 10TH ST
COLUMBUS GA
31901-2851
US

IV. Provider business mailing address

2100 COMER AVE
COLUMBUS GA
31904-8725
US

V. Phone/Fax

Practice location:
  • Phone: 706-653-4258
  • Fax:
Mailing address:
  • Phone: 706-596-5737
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License Number1441
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: