MEDICARE: FIRST STEP PEDIATRIC PSYCHOLOGY CONSULTANTS, 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
1	251S00000X	Community/Behavioral Health Agency	PY003365	GA

General Provider Information

NPI Number	:	1306165634
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	FIRST STEP PEDIATRIC PSYCHOLOGY CONSULTANTS, LLC

Provider Business Mailing Address
First Line	:	1415 HIGHWAY 85 N STE 310-222
Second Line	:
City	:	FAYETTEVILLE
State	:	GA
Zip	:	30214-7738
Country	:	US
Telephone Number	:	678-462-5478
Fax Number	:

Provider Business Practice Location Address
First Line	:	1415 HIGHWAY 85 N STE 310-222
Second Line	:
City	:	FAYETTEVILLE
State	:	GA
Zip	:	30214-7738
Country	:	US
Telephone Number	:	678-462-5478
Fax Number	:

Authorized Official
Title or Position	:	CEO/LICENSED PSYCHOLOGIST
Name	:	DR. TIFFANY GILMORE RANDELL
Credential	:	PSY.D.
Telephone Number	:	678-462-5478

Provider Enumeration Date	:	05/26/2010
Last Update Date	:	05/26/2010

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