=====================================================
General NPI Number Information
=====================================================
NPI Number | 1336217330
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | THE PSYCHOLOGIST, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/30/2006
-----------------------------------------------------
Last Update Date | 08/28/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 268 S 7TH ST
-----------------------------------------------------
City | GADSDEN
-----------------------------------------------------
State | AL
-----------------------------------------------------
Zip | 35901-4133
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 256-547-3266
-----------------------------------------------------
Fax | 256-547-3267
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 268 S 7TH ST
-----------------------------------------------------
City | GADSDEN
-----------------------------------------------------
State | AL
-----------------------------------------------------
Zip | 35901-4133
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 256-547-3266
-----------------------------------------------------
Fax | 256-547-3267
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER'PSYCHOLOGIST
-----------------------------------------------------
Name | DR. ALBERT BARTOW RAY JR.
-----------------------------------------------------
Credential | PH.D.
-----------------------------------------------------
Telephone | 256-547-3266
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103T00000X
-----------------------------------------------------
Taxonomy Name | Psychologist
-----------------------------------------------------
License Number | 1294
-----------------------------------------------------
License Number State | AL
-----------------------------------------------------