=====================================================
General NPI Number Information
=====================================================
NPI Number | 1447585666
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | RAUSHANNAH N. JOHNSON-VERWAYNE PSY. D.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/06/2009
-----------------------------------------------------
Last Update Date | 06/18/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3915 CASCADE RD SW SUITE T-90
-----------------------------------------------------
City | ATLANTA
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30331-8512
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 678-973-2491
-----------------------------------------------------
Fax | 404-745-8485
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 130 WYNFIELD WAY SW
-----------------------------------------------------
City | ATLANTA
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30331-6837
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 757-879-0639
-----------------------------------------------------
Fax | 404-745-8485
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103T00000X
-----------------------------------------------------
Taxonomy Name | Psychologist
-----------------------------------------------------
License Number | PSY003324
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------