Healthcare Provider Details

I. General information

NPI: 1487986493
Provider Name (Legal Business Name): CHATTAHOOCHEE CHILD PSYCHOLOGY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/02/2010
Last Update Date: 08/28/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

430 PRIOR STREET NE
GAINESVILLE GA
30501
US

IV. Provider business mailing address

430 PRIOR STREET NE
GAINESVILLE GA
30501
US

V. Phone/Fax

Practice location:
  • Phone: 678-971-5355
  • Fax: 678-971-5359
Mailing address:
  • Phone: 678-971-5355
  • Fax: 678-971-5359

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC2200X
TaxonomyClinical Child & Adolescent Psychologist
License Number3114
License Number StateGA

VIII. Authorized Official

Name: DR. KRISTEN W GREEN
Title or Position: OWNER/PSYCHOLOGIST
Credential: PHD
Phone: 678-971-5355