MEDICARE: SKYTHERAPIST MANAGEMENT SERVICES ORGANIZATION, INC

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	103T00000X	Psychologist

General Provider Information

NPI Number	:	1508581661
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SKYTHERAPIST MANAGEMENT SERVICES ORGANIZATION, INC

Provider Business Mailing Address
First Line	:	4480 S COBB DR SE UNIT 503
Second Line	:
City	:	SMYRNA
State	:	GA
Zip	:	30080-6990
Country	:	US
Telephone Number	:	404-579-9167
Fax Number	:

Provider Business Practice Location Address
First Line	:	1169 EASTERN PKWY STE 2231
Second Line	:
City	:	LOUISVILLE
State	:	KY
Zip	:	40217-1426
Country	:	US
Telephone Number	:	404-579-9167
Fax Number	:

Authorized Official
Title or Position	:	CEO
Name	:	MR. KEITH JONES
Credential	:
Telephone Number	:	404-579-9167

Provider Enumeration Date	:	10/11/2022
Last Update Date	:	10/11/2022

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