Healthcare Provider Details

I. General information

NPI: 1053812537
Provider Name (Legal Business Name): CARMEN JULIA NEYRA PH.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/21/2018
Last Update Date: 02/21/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4939 LOWER ROSWELL RD BLDG C
MARIETTA GA
30068-4338
US

IV. Provider business mailing address

4939 LOWER ROSWELL RD BLDG C
MARIETTA GA
30068-4338
US

V. Phone/Fax

Practice location:
  • Phone: 404-915-3987
  • Fax: 770-578-0860
Mailing address:
  • Phone: 404-915-3987
  • Fax: 770-578-0860

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPSY002108
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: