Provider Demographics
NPI:1902276686
Name:DOUGLASVILLE OUTPATIENT PSYCHOLOGICAL SERVICES
Entity Type:Organization
Organization Name:DOUGLASVILLE OUTPATIENT PSYCHOLOGICAL SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LPC
Authorized Official - Prefix:
Authorized Official - First Name:MICHELLA
Authorized Official - Middle Name:
Authorized Official - Last Name:JONES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:678-838-9336
Mailing Address - Street 1:8304 OFFICE PARK DR
Mailing Address - Street 2:
Mailing Address - City:DOUGLASVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30134-6935
Mailing Address - Country:US
Mailing Address - Phone:678-838-9336
Mailing Address - Fax:
Practice Address - Street 1:2722 STILLWATER LAKE LN
Practice Address - Street 2:
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30066-7906
Practice Address - Country:US
Practice Address - Phone:770-265-8336
Practice Address - Fax:770-578-1006
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-10-07
Last Update Date:2015-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALPC007582101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty