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General NPI Number Information
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NPI Number | 1528289436
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Entity Type | Individual
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Provider Name | MADINAH IKHLAS RALSTON PH.D.
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Gender | Female
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Dates
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Enumeration Date | 05/01/2007
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Last Update Date | 07/08/2007
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Provider Practice Location Address
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Address Line | 1631 PHOENIX BLVD SUITE 5
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City | COLLEGE PARK
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State | GA
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Zip | 30349-5545
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Country | US
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Telephone | 770-909-6550
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Fax | 770-909-6551
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Provider Business Mailing Address
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Address Line | 7059 RED MAPLE LN
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City | LITHONIA
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State | GA
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Zip | 30058-2998
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Country | US
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Telephone | 404-432-5259
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Fax | 770-482-7868
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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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 | PSY003079
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License Number State | GA
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