=====================================================
General NPI Number Information
=====================================================
NPI Number | 1538279641
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MAGUIRE & MOORE PSYCLOLOGICAL SERVICES
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/30/2006
-----------------------------------------------------
Last Update Date | 11/19/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 448 TELFAIR ST
-----------------------------------------------------
City | AUGUSTA
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30901-5811
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 706-722-7788
-----------------------------------------------------
Fax | 706-724-8300
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 448 TELFAIR ST
-----------------------------------------------------
City | AUGUSTA
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30901-5811
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 706-722-7788
-----------------------------------------------------
Fax | 706-724-8300
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MS, LPC/PARTNER
-----------------------------------------------------
Name | SADIE C. MAGUIRE
-----------------------------------------------------
Credential | LPC
-----------------------------------------------------
Telephone | 706-722-7788
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103T00000X
-----------------------------------------------------
Taxonomy Name | Psychologist
-----------------------------------------------------
License Number | LPC 1325
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------