Provider Demographics
NPI:1043581671
Name:PREFERRED PSYCHOLOGICAL SERVICE, LLC
Entity Type:Organization
Organization Name:PREFERRED PSYCHOLOGICAL SERVICE, LLC
Other - Org Name:PREFERRED PSYCHOLOGICAL SERVIC, LLC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:MRS
Authorized Official - First Name:EVA
Authorized Official - Middle Name:DIANE
Authorized Official - Last Name:MARTIN
Authorized Official - Suffix:
Authorized Official - Credentials:LPC
Authorized Official - Phone:678-606-0680
Mailing Address - Street 1:PO BOX 4426
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:GA
Mailing Address - Zip Code:30114-0200
Mailing Address - Country:US
Mailing Address - Phone:678-303-0380
Mailing Address - Fax:
Practice Address - Street 1:24 WALESKA ST
Practice Address - Street 2:SUITE 100
Practice Address - City:CANTON
Practice Address - State:GA
Practice Address - Zip Code:30114-2739
Practice Address - Country:US
Practice Address - Phone:678-606-0680
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-01-12
Last Update Date:2012-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty