=====================================================
General NPI Number Information
=====================================================
NPI Number | 1184070575
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PSYCHOLOGICAL DIAGNOSTIC CENTER, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/04/2016
-----------------------------------------------------
Last Update Date | 05/04/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1827 POWERS FERRY RD SE BUILDING 22, SUITE 200
-----------------------------------------------------
City | ATLANTA
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30339-5621
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 770-953-4744
-----------------------------------------------------
Fax | 770-953-4640
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1827 POWERS FERRY RD SE BUILDING 22, SUITE 200
-----------------------------------------------------
City | ATLANTA
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30339-5621
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 770-953-4744
-----------------------------------------------------
Fax | 770-953-4640
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | LICENSED PSYCHOLOGIST
-----------------------------------------------------
Name | DR. WILLA L BOSTON
-----------------------------------------------------
Credential | PSY.D.
-----------------------------------------------------
Telephone | 770-953-4744
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103TC0700X
-----------------------------------------------------
Taxonomy Name | Clinical Psychologist
-----------------------------------------------------
License Number | PSY003953
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------