Healthcare Provider Details

I. General information

NPI: 1396277968
Provider Name (Legal Business Name): PSYCHIATRIC PROFESSIONALS OF GEORGIA, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/01/2017
Last Update Date: 05/21/2026
Certification Date: 05/21/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1325 SATELLITE BLVD NW BLDG 400
SUWANEE GA
30024-4651
US

IV. Provider business mailing address

1325 SATELLITE BLVD NW BLDG 400
SUWANEE GA
30024-4651
US

V. Phone/Fax

Practice location:
  • Phone: 678-263-3080
  • Fax: 678-496-9863
Mailing address:
  • Phone: 678-263-3080
  • Fax: 678-496-9863

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084A0401X
TaxonomyAddiction Medicine (Psychiatry & Neurology) Physician
License Number58297
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License Number060325
License Number StateGA
# 3
Primary TaxonomyN
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License Number59016
License Number StateGA
# 4
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number55563
License Number StateGA

VIII. Authorized Official

Name: KALEY DAVIS
Title or Position: PROVIDER ENROLLMENT ASSOCIATE
Credential:
Phone: 470-857-4412