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General NPI Number Information
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NPI Number | 1083779763
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Entity Type | Organization
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Legal Business Name | PSYCHOGENESIS, INC.
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Dates
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Enumeration Date | 12/24/2006
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Last Update Date | 12/03/2015
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Provider Practice Location Address
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Address Line | 519 BROAD ST SUITE 202
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City | ROME
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State | GA
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Zip | 30161-1734
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Country | US
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Telephone | 706-232-5544
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Fax | 888-543-1173
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Provider Business Mailing Address
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Address Line | 2 WINDSOR RD SW
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City | ROME
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State | GA
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Zip | 30165-8555
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Country | US
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Telephone | 706-232-5544
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Fax | 888-543-1173
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. JUDITH TUTIN
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Credential | PH.D.
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Telephone | 706-232-5544
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103TC0700X
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Taxonomy Name | Clinical Psychologist
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License Number | 2075
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License Number State | GA
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