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General NPI Number Information
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NPI Number | 1356608459
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Entity Type | Organization
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Legal Business Name | CHILD AND FAMILY PSYCHOTHERAPY CENTER
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Dates
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Enumeration Date | 04/13/2012
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Last Update Date | 04/13/2012
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Provider Practice Location Address
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Address Line | 680 DOUTHIT FERRY RD SUITE 106
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City | CARTERSVILLE
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State | GA
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Zip | 30120-4150
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Country | US
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Telephone | 770-334-8461
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Fax | 770-334-8624
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Provider Business Mailing Address
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Address Line | 680 DOUTHIT FERRY RD SUITE 106
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City | CARTERSVILLE
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State | GA
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Zip | 30120-4150
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Country | US
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Telephone | 770-334-8461
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Fax | 770-334-8624
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Authorized Official
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Title or Position | LICENSED PSYCHOLOGIST
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Name | DR. MARY B SUMMERVILLE
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Credential | PHD
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Telephone | 770-334-8461
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103T00000X
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Taxonomy Name | Psychologist
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License Number | PSY001432
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License Number State | GA
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