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General NPI Number Information
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NPI Number | 1134310980
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Entity Type | Organization
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Legal Business Name | SUMMITRIDGE
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Dates
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Enumeration Date | 08/07/2007
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Last Update Date | 08/07/2007
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Provider Practice Location Address
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Address Line | 250 SCENIC HWY
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City | LAWRENCEVILLE
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State | GA
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Zip | 30045-5675
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Country | US
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Telephone | 678-312-3585
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Fax | 678-312-5915
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Provider Business Mailing Address
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Address Line | 250 SCENIC HWY
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City | LAWRENCEVILLE
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State | GA
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Zip | 30045-5675
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Country | US
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Telephone | 678-312-3585
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Fax | 678-312-5915
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Authorized Official
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Title or Position | ASSESSMENT CSLR
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Name | MR. MATTHEW CAUDILL
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Credential | LCSW
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Telephone | 678-312-5850
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 283Q00000X
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Taxonomy Name | Psychiatric Hospital
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License Number |
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License Number State |
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