Healthcare Provider Details

I. General information

NPI: 1437323029
Provider Name (Legal Business Name): SBS PSYCHOLOGICAL ASSOCIATES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/15/2008
Last Update Date: 04/15/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

485 S PERRY ST SUITE D
LAWRENCEVILLE GA
30045-4923
US

IV. Provider business mailing address

PO BOX 2133
LAWRENCEVILLE GA
30046-2133
US

V. Phone/Fax

Practice location:
  • Phone: 678-205-0838
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number002451
License Number StateGA

VIII. Authorized Official

Name: DR. SHIRLEY BOONE-SANFORD
Title or Position: CEO
Credential: PH.D.
Phone: 678-205-0838