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General NPI Number Information
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NPI Number | 1114085743
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Entity Type | Organization
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Legal Business Name | SWEETWATER PSYCHOLOGICAL ASSOCIATES, LLC
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Dates
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Enumeration Date | 12/05/2006
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Last Update Date | 08/10/2007
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Provider Practice Location Address
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Address Line | 2625 SANDY PLAINS RD STE 202 SECONDARY LOCATION
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City | MARIETTA
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State | GA
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Zip | 30066-4291
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Country | US
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Telephone | 770-732-0983
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Fax | 770-732-1283
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Provider Business Mailing Address
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Address Line | PO BOX 1078
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City | LITHIA SPRINGS
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State | GA
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Zip | 30122-1078
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Country | US
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Telephone | 770-732-0982
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Fax | 770-732-1283
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Authorized Official
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Title or Position | OWNER/PARTNER
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Name | DR. DAVID CLYDE MARTIN
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Credential | PH.D.
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Telephone | 770-732-0982
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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 | PSY001157
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License Number State | GA
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Taxonomy #2
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number | CSW000729
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License Number State | GA
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Taxonomy #3
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Taxonomy Code | 103TC0700X
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Taxonomy Name | Clinical Psychologist
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License Number | PSY001373
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License Number State | GA
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