Healthcare Provider Details

I. General information

NPI: 1083042105
Provider Name (Legal Business Name): PSYCHIATRIC CONSULTING SERVICES OF SOUTH GEORGIA, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/29/2013
Last Update Date: 01/18/2024
Certification Date: 01/18/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2109 N PATTERSON ST STE B
VALDOSTA GA
31602-2577
US

IV. Provider business mailing address

2109 N PATTERSON ST STE B
VALDOSTA GA
31602-2577
US

V. Phone/Fax

Practice location:
  • Phone: 229-232-4833
  • Fax: 877-343-0538
Mailing address:
  • Phone: 229-232-4833
  • Fax: 877-343-0538

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: WENDY LIANA VANDEMARK
Title or Position: OWNER
Credential: MD
Phone: 229-232-4833