=====================================================
General NPI Number Information
=====================================================
NPI Number | 1871861468
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SARA RACHEL DECKELBAUM PSY.D.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/09/2011
-----------------------------------------------------
Last Update Date | 12/09/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4939 LOWER ROSWELL RD SUITE B-202
-----------------------------------------------------
City | MARIETTA
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30068-4338
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 770-971-3303
-----------------------------------------------------
Fax | 770-971-3314
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4939 LOWER ROSWELL RD SUITE B-202
-----------------------------------------------------
City | MARIETTA
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30068-4338
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 770-971-3303
-----------------------------------------------------
Fax | 770-971-3314
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103TC0700X
-----------------------------------------------------
Taxonomy Name | Clinical Psychologist
-----------------------------------------------------
License Number | PSY003522
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------