Healthcare Provider Details

I. General information

NPI: 1366626970
Provider Name (Legal Business Name): BUDDINGTON PSYCHOLOGY CLINIC, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/19/2007
Last Update Date: 12/19/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4485 TENCH RD SUITE 840
SUWANEE GA
30024-6741
US

IV. Provider business mailing address

4485 TENCH RD SUITE 840
SUWANEE GA
30024-6741
US

V. Phone/Fax

Practice location:
  • Phone: 770-493-9177
  • Fax: 770-945-7214
Mailing address:
  • Phone: 770-493-9177
  • Fax: 770-945-7214

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License NumberPSY001926
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberCSW003357
License Number StateGA

VIII. Authorized Official

Name: ROGER W. BUDDINGTON
Title or Position: PRESIDENT
Credential: PH.D.
Phone: 770-493-9177