=====================================================
General NPI Number Information
=====================================================
NPI Number | 1700190600
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ACADEMY PSYCHOLOGICAL SERVICES,INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/03/2010
-----------------------------------------------------
Last Update Date | 08/03/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5165 LAVISTA RD
-----------------------------------------------------
City | TUCKER
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30084-3602
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 404-558-9830
-----------------------------------------------------
Fax | 770-939-6781
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5165 LAVISTA RD
-----------------------------------------------------
City | TUCKER
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30084-3602
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 404-558-9830
-----------------------------------------------------
Fax | 770-939-6781
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PSYCHOLOGIST
-----------------------------------------------------
Name | DR. DEVORAH A GIFFEN
-----------------------------------------------------
Credential | PSY
-----------------------------------------------------
Telephone | 404-558-9830
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103G00000X
-----------------------------------------------------
Taxonomy Name | Clinical Neuropsychologist
-----------------------------------------------------
License Number | PSY001764
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------