Healthcare Provider Details

I. General information

NPI: 1093555989
Provider Name (Legal Business Name): PSYCHOLOGICAL CONSULTANTS OF GEORGIA PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/29/2024
Last Update Date: 05/29/2024
Certification Date: 05/29/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5284 FLOYD RD SW UNIT 1216
MABLETON GA
30126-6109
US

IV. Provider business mailing address

5284 FLOYD RD SW UNIT 1216
MABLETON GA
30126-6109
US

V. Phone/Fax

Practice location:
  • Phone: 404-936-2346
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DR. CARMINE COSTELLO
Title or Position: PRESIDENT
Credential: DO
Phone: 404-936-2346