Healthcare Provider Details

I. General information

NPI: 1376728394
Provider Name (Legal Business Name): PSYCHOLOGICAL AFFILIATES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/09/2008
Last Update Date: 01/09/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

122 CHERRY ST NE
MARIETTA GA
30060-7206
US

IV. Provider business mailing address

122 CHERRY ST NE
MARIETTA GA
30060-7206
US

V. Phone/Fax

Practice location:
  • Phone: 770-427-2911
  • Fax:
Mailing address:
  • Phone: 770-427-2911
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number000669 GA
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number001135 GA
License Number StateGA
# 3
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberGA CSW003681
License Number StateGA

VIII. Authorized Official

Name: JACK HOLLAND GRISHAM
Title or Position: PRESIDENT
Credential: PH.D.
Phone: 770-427-2911