Healthcare Provider Details

I. General information

NPI: 1013319847
Provider Name (Legal Business Name): GWINNETT PSYCHOLOGY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/24/2014
Last Update Date: 09/24/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1805 HERRINGTON RD BLDG. 2
LAWRENCEVILLE GA
30043-7987
US

IV. Provider business mailing address

1805 HERRINGTON RD BLDG. 2
LAWRENCEVILLE GA
30043-7987
US

V. Phone/Fax

Practice location:
  • Phone: 507-722-2402
  • Fax: 770-962-1886
Mailing address:
  • Phone: 507-722-2402
  • Fax: 770-962-1886

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License NumberPSY0003641
License Number StateGA

VIII. Authorized Official

Name: DR. CASSIN COLE-STRAUB
Title or Position: ORGANIZER/PSYCHOLOGIST
Credential: PSY.D.
Phone: 507-722-2402