Healthcare Provider Details

I. General information

NPI: 1336094234
Provider Name (Legal Business Name): SOUBLIS PSYCHOLOGICAL ASSOCIATES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/04/2026
Last Update Date: 03/04/2026
Certification Date: 03/04/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1003 BOMBAY LN
ROSWELL GA
30076-5820
US

IV. Provider business mailing address

1003 BOMBAY LN
ROSWELL GA
30076-5820
US

V. Phone/Fax

Practice location:
  • Phone: 678-782-2560
  • Fax: 678-782-2560
Mailing address:
  • Phone: 678-782-2560
  • Fax: 678-782-2560

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License Number
License Number State

VIII. Authorized Official

Name: THEODORA SOUBLIS
Title or Position: DIRECTOR
Credential: PHD
Phone: 770-362-4815