Healthcare Provider Details

I. General information

NPI: 1720110398
Provider Name (Legal Business Name): GWINNETT PSYCHIATRY, P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/09/2007
Last Update Date: 06/06/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

170 CAMDEN HILL RD SUITE C
LAWRENCEVILLE GA
30046-7418
US

IV. Provider business mailing address

170 CAMDEN HILL RD SUITE C
LAWRENCEVILLE GA
30046-7418
US

V. Phone/Fax

Practice location:
  • Phone: 678-226-2295
  • Fax: 678-226-2296
Mailing address:
  • Phone: 678-226-2295
  • Fax: 678-226-2296

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number056642
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number056642
License Number StateGA

VIII. Authorized Official

Name: DR. NASIRA RUBINA
Title or Position: PRESIDENT
Credential: M.D.
Phone: 678-749-6063