Healthcare Provider Details

I. General information

NPI: 1154515278
Provider Name (Legal Business Name): JOHN MAULDIN PHD LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/31/2007
Last Update Date: 10/15/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2404 REFUGE RD
JASPER GA
30143-4946
US

IV. Provider business mailing address

2404 REFUGE RD
JASPER GA
30143-4946
US

V. Phone/Fax

Practice location:
  • Phone: 706-579-2247
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License NumberPSY001342
License Number StateGA

VIII. Authorized Official

Name: DR. JOHN MAULDIN JR.
Title or Position: OWNER
Credential: PH.D.
Phone: 706-402-3525