Healthcare Provider Details

I. General information

NPI: 1053237859
Provider Name (Legal Business Name): PSYCH AND SPOON
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/25/2026
Last Update Date: 07/15/2026
Certification Date: 07/15/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

123 WHEEHAW RD
MACON GA
31211-7013
US

IV. Provider business mailing address

123 WHEEHAW RD
MACON GA
31211-7013
US

V. Phone/Fax

Practice location:
  • Phone: 478-973-8627
  • Fax:
Mailing address:
  • Phone: 478-973-8627
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number
License Number State

VIII. Authorized Official

Name: LAREACA BOSTICK
Title or Position: FOUNDER
Credential: LCSW
Phone: 478-973-8627