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General NPI Number Information
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NPI Number | 1467722397
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Entity Type | Organization
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Legal Business Name | CORNERSTONE PSYCHOLOGICAL CENTER
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Dates
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Enumeration Date | 01/10/2012
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Last Update Date | 01/10/2012
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Provider Practice Location Address
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Address Line | 1897 GODBY RD
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City | COLLEGE PARK
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State | GA
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Zip | 30349-5235
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Country | US
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Telephone | 770-996-7622
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Fax | 770-996-5469
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Provider Business Mailing Address
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Address Line | 1897 GODBY RD
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City | COLLEGE PARK
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State | GA
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Zip | 30349-5235
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Country | US
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Telephone | 770-996-7622
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Fax | 770-996-5469
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Authorized Official
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Title or Position | CEO
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Name | DR. SHERRY L BLAKE
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Credential | PHD
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Telephone | 770-996-7622
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103TC0700X
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Taxonomy Name | Clinical Psychologist
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License Number | PSY001267
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License Number State | GA
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