=====================================================
General NPI Number Information
=====================================================
NPI Number | 1457741829
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CARREFOUR OF ATLANTA PSYCHOLOGICAL HEALTH INSTITUTE LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/23/2015
-----------------------------------------------------
Last Update Date | 01/23/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2751 BUFORD HWY NE STE 700
-----------------------------------------------------
City | ATLANTA
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30324-3207
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 678-687-9149
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2465 MAIN ST UNIT 307
-----------------------------------------------------
City | EAST POINT
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30344-2675
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 678-687-9149
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | LICENSED PSYCHOLOGIST
-----------------------------------------------------
Name | DR. LYDIA ODENAT
-----------------------------------------------------
Credential | PHD
-----------------------------------------------------
Telephone | 678-687-9149
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103T00000X
-----------------------------------------------------
Taxonomy Name | Psychologist
-----------------------------------------------------
License Number | PSY003854
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------