Provider Demographics
NPI:1861998585
Name:PEACHTREE PEDIATRIC PSYCHOLOGY, LLC
Entity type:Organization
Organization Name:PEACHTREE PEDIATRIC PSYCHOLOGY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LICENSED PSYCHOLOGIST
Authorized Official - Prefix:DR
Authorized Official - First Name:AVITAL
Authorized Official - Middle Name:K
Authorized Official - Last Name:COHEN
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD
Authorized Official - Phone:404-796-7777
Mailing Address - Street 1:750 HAMMOND DRIVE
Mailing Address - Street 2:BLDG 7, STE 200
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30328
Mailing Address - Country:US
Mailing Address - Phone:404-796-7777
Mailing Address - Fax:
Practice Address - Street 1:750 HAMMOND DRIVE
Practice Address - Street 2:BLDG 7, STE 200
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30328
Practice Address - Country:US
Practice Address - Phone:404-796-7777
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-04-02
Last Update Date:2018-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA3672103TM1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TM1800XBehavioral Health & Social Service ProvidersPsychologistIntellectual & Developmental DisabilitiesGroup - Multi-Specialty