Healthcare Provider Details

I. General information

NPI: 1346154887
Provider Name (Legal Business Name): KIRK RICHARD ELLIS PSYD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/01/2026
Last Update Date: 10/01/2026
Certification Date: 10/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4038 JORDAN LAKE DR
MARIETTA GA
30062-5786
US

IV. Provider business mailing address

4038 JORDAN LAKE DR
MARIETTA GA
30062-5786
US

V. Phone/Fax

Practice location:
  • Phone: 404-323-4665
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number2337
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: