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NPI Code Detail

MEDICARE: DECATUR PSYCHOLOGY, LLC

MEDICARE: DECATUR PSYCHOLOGY, LLC
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
1103TC0700XClinical PsychologistPSY001911GA

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
11134380322OTHERGAINDIVIDUAL NPI

General Provider Information

NPI Number : 1194013912
Entity Type Code : Organization
Provider Name (Legal Business Name) : DECATUR PSYCHOLOGY, LLC
Provider Business Mailing Address
First Line : 101 BIRCH ST
Second Line :
City : DECATUR
State : GA
Zip : 30030-3340
Country : US
Telephone Number : 404-513-6077
Fax Number : 404-478-6823
Provider Business Practice Location Address
First Line : 101 BIRCH ST
Second Line :
City : DECATUR
State : GA
Zip : 30030-3340
Country : US
Telephone Number : 404-513-6077
Fax Number : 404-478-6823
Authorized Official
Title or Position : OWNER
Name : DR. JOHN RACKLEY LUCY
Credential : PHD
Telephone Number : 404-513-6077
Provider Enumeration Date : 07/13/2011
Last Update Date : 05/26/2021

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