MEDICARE: DR. ELAINE EASSA PH.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103TC0700X	Clinical Psychologist	002323	GA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1184794778
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. ELAINE EASSA PH.D.

Provider Business Mailing Address
First Line	:	1827 POWERS FERRY RD SE
Second Line	:	BLDG 22 STE 200
City	:	ATLANTA
State	:	GA
Zip	:	30339-5621
Country	:	US
Telephone Number	:	770-953-4744
Fax Number	:	770-953-4640

Provider Business Practice Location Address
First Line	:	1827 POWERS FERRY RD SE
Second Line	:	BLDG 22 STE 200
City	:	ATLANTA
State	:	GA
Zip	:	30339-5621
Country	:	US
Telephone Number	:	770-953-4744
Fax Number	:	770-953-4640

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/09/2006
Last Update Date	:	07/08/2007

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