Healthcare Provider Details

I. General information

NPI: 1245801075
Provider Name (Legal Business Name): GEORGIA PSYCH SERVICES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/02/2021
Last Update Date: 08/24/2021
Certification Date: 08/24/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4922 BILL GARDNER PKWY # 2
LOCUST GROVE GA
30248-3647
US

IV. Provider business mailing address

3593 MEDINA LINE RD 181
MEDINA OH
44256
US

V. Phone/Fax

Practice location:
  • Phone: 330-536-3746
  • Fax: 330-267-4250
Mailing address:
  • Phone: 330-664-9250
  • Fax: 330-267-4250

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: ROBERT SEAN RAE
Title or Position: CEO
Credential: MD
Phone: 330-536-3746