Healthcare Provider Details

I. General information

NPI: 1114085743
Provider Name (Legal Business Name): SWEETWATER PSYCHOLOGICAL ASSOCIATES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/05/2006
Last Update Date: 08/10/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2625 SANDY PLAINS RD STE 202 SECONDARY LOCATION
MARIETTA GA
30066-4291
US

IV. Provider business mailing address

PO BOX 1078
LITHIA SPRINGS GA
30122-1078
US

V. Phone/Fax

Practice location:
  • Phone: 770-732-0983
  • Fax: 770-732-1283
Mailing address:
  • Phone: 770-732-0982
  • Fax: 770-732-1283

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPSY001157
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberCSW000729
License Number StateGA
# 3
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPSY001373
License Number StateGA

VIII. Authorized Official

Name: DR. DAVID CLYDE MARTIN
Title or Position: OWNER/PARTNER
Credential: PH.D.
Phone: 770-732-0982