Provider Demographics
NPI:1730138207
Name:DANIEL, THEODORE ALEXANDER (PSYCHOLOGIST/PSYD)
Entity type:Individual
Prefix:DR
First Name:THEODORE
Middle Name:ALEXANDER
Last Name:DANIEL
Suffix:
Gender:M
Credentials:PSYCHOLOGIST/PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:2807 SPRINGWOOD DR
Mailing Address - Street 2:
Mailing Address - City:AUGUSTA
Mailing Address - State:GA
Mailing Address - Zip Code:30909-2332
Mailing Address - Country:US
Mailing Address - Phone:706-738-3621
Mailing Address - Fax:706-738-3621
Practice Address - Street 1:1287 MARKS CHURCH RD
Practice Address - Street 2:SUITE F
Practice Address - City:AUGUSTA
Practice Address - State:GA
Practice Address - Zip Code:30909-6330
Practice Address - Country:US
Practice Address - Phone:706-481-8181
Practice Address - Fax:706-650-8427
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA1662103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00546433AMedicaid
GA68BBCMXMedicare ID - Type Unspecified
GA00546433AMedicaid