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General NPI Number Information
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NPI Number | 1871033654
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Entity Type | Organization
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Legal Business Name | COASTAL GEORGIA PSYCHODYNAMIC CENTER, LLC
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Dates
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Enumeration Date | 02/28/2017
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Last Update Date | 05/11/2020
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Provider Practice Location Address
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Address Line | 325 S WALNUT ST
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City | STATESBORO
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State | GA
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Zip | 30458-5418
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Country | US
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Telephone | 912-421-9050
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Fax | 912-623-4918
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Provider Business Mailing Address
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Address Line | 325 S WALNUT ST
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City | STATESBORO
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State | GA
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Zip | 30458-5418
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Country | US
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Telephone | 912-421-9050
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Fax | 912-623-4918
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Authorized Official
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Title or Position | ORGANIZER
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Name | DR. AMANDA RICKARD
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Credential |
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Telephone | 912-421-9050
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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 | PSY003907
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License Number State | GA
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