=====================================================
General NPI Number Information
=====================================================
NPI Number | 1790992360
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PSYCHOLOGICAL SERVICES OF COASTAL GEORGIA, PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/16/2007
-----------------------------------------------------
Last Update Date | 12/10/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 10375 FORD AVE STE 2
-----------------------------------------------------
City | RICHMOND HILL
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 31324-8811
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 912-756-5696
-----------------------------------------------------
Fax | 912-756-5636
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 970
-----------------------------------------------------
City | RICHMOND HILL
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 31324-0970
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 912-756-5696
-----------------------------------------------------
Fax | 912-756-5636
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PSYCHOLOGIST
-----------------------------------------------------
Name | DR. BRENDA SUE RICHARDSON
-----------------------------------------------------
Credential | PH.D
-----------------------------------------------------
Telephone | 912-756-5696
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103T00000X
-----------------------------------------------------
Taxonomy Name | Psychologist
-----------------------------------------------------
License Number | 0931
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------