Healthcare Provider Details

I. General information

NPI: 1467562827
Provider Name (Legal Business Name): SWEETWATER PSYCHOLOGICAL ASSOCIATES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/30/2006
Last Update Date: 10/27/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

560 THORNTON RD SUITE 106
LITHIA SPRINGS GA
30122-1655
US

IV. Provider business mailing address

PO BOX 1078
LITHIA SPRINGS GA
30122-7078
US

V. Phone/Fax

Practice location:
  • Phone: 770-732-0982
  • Fax: 770-732-1283
Mailing address:
  • Phone: 770-732-0982
  • Fax: 770-732-1283

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License NumberPSY001373, PSY001157
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code103TB0200X
TaxonomyCognitive & Behavioral Psychologist
License NumberPSY001373
License Number StateGA
# 3
Primary TaxonomyN
Taxonomy Code103TB0200X
TaxonomyCognitive & Behavioral Psychologist
License NumberPSY001157
License Number StateGA
# 4
Primary TaxonomyN
Taxonomy Code103TC2200X
TaxonomyClinical Child & Adolescent Psychologist
License NumberPSY001373, PSY001157
License Number StateGA
# 5
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberCSW000729
License Number StateGA
# 6
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPSY001373,PSY001157
License Number StateGA

VIII. Authorized Official

Name: DAVID C MARTIN
Title or Position: OWNER PARTNER
Credential: PH.D
Phone: 770-732-0982