Healthcare Provider Details

I. General information

NPI: 1487617197
Provider Name (Legal Business Name): MTJ PSYCHIATRIC SERVICES INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/11/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1291 STANLEY RD
KENNESAW GA
30152
US

IV. Provider business mailing address

5907 BUCKNER CREEK DR
MABLETON GA
30126
US

V. Phone/Fax

Practice location:
  • Phone: 770-427-0147
  • Fax: 770-427-4699
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC2200X
TaxonomyClinical Child & Adolescent Psychologist
License Number049301
License Number StateGA

VIII. Authorized Official

Name: DR. MARTIN THOMAS JOHNSON
Title or Position: CEO
Credential: MD
Phone: 678-984-7557