Healthcare Provider Details

I. General information

NPI: 1871188771
Provider Name (Legal Business Name): SOUTHEAST PSYCH SERVICES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/03/2021
Last Update Date: 08/13/2026
Certification Date: 08/13/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3355 SAINT JOHNS LN STE F
ELLICOTT CITY MD
21042-2600
US

IV. Provider business mailing address

1265 INTERSTATE PKWY STE B
AUGUSTA GA
30909-6481
US

V. Phone/Fax

Practice location:
  • Phone: 706-204-1493
  • Fax: 855-264-6670
Mailing address:
  • Phone: 706-204-1366
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State

VIII. Authorized Official

Name: DAVIS DEBRADY
Title or Position: DIRECTOR
Credential:
Phone: 706-204-1493