MEDICARE: THERAPY NETWORKS AND PSYCHOLOGICAL SERVICES

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

General Provider Information

NPI Number	:	1336835669
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	THERAPY NETWORKS AND PSYCHOLOGICAL SERVICES

Provider Business Mailing Address
First Line	:	2048 LAWRENCEVILLE HWY UNIT 33111
Second Line	:
City	:	DECATUR
State	:	GA
Zip	:	30033-6201
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	175 BRADFORD SQ
Second Line	:
City	:	FAYETTEVILLE
State	:	GA
Zip	:	30215-1967
Country	:	US
Telephone Number	:	404-482-1014
Fax Number	:

Authorized Official
Title or Position	:	CLINICAL PSYCHOLOGIST
Name	:	ADRIA HICKSON
Credential	:	PSYD
Telephone Number	:	404-482-1014

Provider Enumeration Date	:	04/11/2023
Last Update Date	:	04/11/2023

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