=====================================================
General NPI Number Information
=====================================================
NPI Number | 1114880127
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | FAITH PSYCHIATRY LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/05/2025
-----------------------------------------------------
Last Update Date | 12/05/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 650 ROSS AVE
-----------------------------------------------------
City | MILLEN
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30442-1709
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 706-755-5243
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 650 ROSS AVE
-----------------------------------------------------
City | MILLEN
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30442-1709
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 706-755-5243
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MARY L DEVAUL- ESHLAMAN
-----------------------------------------------------
Credential | DO
-----------------------------------------------------
Telephone | 706-755-5243
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103TC0700X
-----------------------------------------------------
Taxonomy Name | Clinical Psychologist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------