Healthcare Provider Details

I. General information

NPI: 1902670490
Provider Name (Legal Business Name): SOUTHSIDE PSYCHIATRIC CONSULTANTS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/14/2023
Last Update Date: 06/17/2025
Certification Date: 06/17/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6572 RIVER PARK DR STE 101G
RIVERDALE GA
30274-2214
US

IV. Provider business mailing address

110 W PIER WAY
FAYETTEVILLE GA
30214-4617
US

V. Phone/Fax

Practice location:
  • Phone: 404-734-4445
  • Fax: 404-745-0552
Mailing address:
  • Phone: 404-734-4666
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number StateNULL
# 2
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number StateNULL

VIII. Authorized Official

Name: MR. RALPH OGWOTU
Title or Position: BUSINESS OWNER
Credential: NP
Phone: 404-734-4445