Healthcare Provider Details

I. General information

NPI: 1336120930
Provider Name (Legal Business Name): TINA MARIE CAUDILL PSY.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/10/2005
Last Update Date: 08/24/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6264 HOSPITAL WAY
DOUGLASVILLE GA
30134-1944
US

IV. Provider business mailing address

PO BOX 1916
DOUGLASVILLE GA
30133-1916
US

V. Phone/Fax

Practice location:
  • Phone: 678-232-9078
  • Fax: 866-489-2642
Mailing address:
  • Phone: 678-232-9078
  • Fax: 866-489-2642

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPSY002899
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: