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General NPI Number Information
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NPI Number | 1104960715
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Entity Type | Individual
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Provider Name | MARK MANFRED ROLAND PH.D.
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Gender | Male
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Dates
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Enumeration Date | 02/16/2007
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Last Update Date | 09/16/2008
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Provider Practice Location Address
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Address Line | 21 TRAMMEL ST. SW PSYCHOLOGICAL CONSULTANTS OF MARIETTA PC
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City | MARIETTA
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State | GA
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Zip | 30064-3249
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Country | US
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Telephone | 770-420-9448
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Fax | 770-420-9441
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Provider Business Mailing Address
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Address Line | PO BOX 515 PSYCHOLOGICAL CONSULTANTS OF MARIETTA PC
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City | MARIETTA
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State | GA
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Zip | 30061-0515
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Country | US
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Telephone | 770-420-9448
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Fax | 770-420-9441
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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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 | 1872
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License Number State | GA
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