Healthcare Provider Details

I. General information

NPI: 1346230208
Provider Name (Legal Business Name): ROBERT J DANIELL PH.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/24/2005
Last Update Date: 03/30/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1701 HARDEE AVE SW
FT MCPHERSON GA
30330-1062
US

IV. Provider business mailing address

1810 HOMESTEAD AVE NE
ATLANTA GA
30306-3136
US

V. Phone/Fax

Practice location:
  • Phone: 404-464-3562
  • Fax: 404-464-4764
Mailing address:
  • Phone: 404-876-1788
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number000426
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: