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General NPI Number Information
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NPI Number | 1194202911
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Entity Type | Organization
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Legal Business Name | SAMUDRA PSYCHOLOGICAL SERVICES LLC
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Dates
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Enumeration Date | 07/24/2018
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Last Update Date | 07/24/2018
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Provider Practice Location Address
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Address Line | 675 SEMINOLE AVE NE STE T03
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City | ATLANTA
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State | GA
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Zip | 30307-3409
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Country | US
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Telephone | 404-249-0520
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Fax |
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Provider Business Mailing Address
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Address Line | 316 SOMERLANE PL
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City | AVONDALE ESTATES
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State | GA
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Zip | 30002-1221
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Country | US
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Telephone | 269-352-7407
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Fax |
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Authorized Official
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Title or Position | LICENSED PSYCHOLOGIST
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Name | DR. ELIZABETH SUE BRADSHAW-LIVINGSTON
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Credential | PHD
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Telephone | 404-249-0520
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QM0801X
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Taxonomy Name | Mental Health Clinic/Center (Including Community Mental Health Center)
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License Number | 003691
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License Number State | GA
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