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General NPI Number Information
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NPI Number | 1093026601
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Entity Type | Organization
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Legal Business Name | JOHN AZAR-DICKENS, PH.D.,PC
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Dates
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Enumeration Date | 06/29/2010
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Last Update Date | 06/29/2010
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Provider Practice Location Address
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Address Line | 109 JOHN MADDOX DR NW
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City | ROME
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State | GA
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Zip | 30165-1451
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Country | US
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Telephone | 706-232-6743
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 1008
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City | ROME
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State | GA
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Zip | 30162-1008
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Country | US
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Telephone | 706-232-6743
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Fax |
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Authorized Official
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Title or Position | LICENSED PSYCHOLOGIST
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Name | DR. JOHN AZAR-DICKENS
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Credential | PH.D.
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Telephone | 706-234-0659
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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 | 002459
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License Number State | GA
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