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General NPI Number Information
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NPI Number | 1902276686
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Entity Type | Organization
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Legal Business Name | DOUGLASVILLE OUTPATIENT PSYCHOLOGICAL SERVICES
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Dates
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Enumeration Date | 10/07/2015
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Last Update Date | 10/07/2015
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Provider Practice Location Address
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Address Line | 2722 STILLWATER LAKE LN
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City | MARIETTA
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State | GA
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Zip | 30066-7906
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Country | US
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Telephone | 770-265-8336
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Fax | 770-578-1006
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Provider Business Mailing Address
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Address Line | 8304 OFFICE PARK DR
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City | DOUGLASVILLE
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State | GA
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Zip | 30134-6935
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Country | US
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Telephone | 678-838-9336
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Fax |
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Authorized Official
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Title or Position | LPC
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Name | MICHELLA JONES
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Credential |
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Telephone | 678-838-9336
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YP2500X
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Taxonomy Name | Professional Counselor
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License Number | LPC007582
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License Number State | GA
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