Provider Demographics
NPI:1073909198
Name:DOUGLASVILLE PSYCHOLOGICAL OUTPATIENT SERVICES
Entity Type:Organization
Organization Name:DOUGLASVILLE PSYCHOLOGICAL OUTPATIENT SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LICENSED PROFESSIONAL COUNSELOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:MICHELLA
Authorized Official - Middle Name:CATHERINE
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 1:8304 OFFICE PARK DR
Practice Address - Street 2:
Practice Address - City:DOUGLASVILLE
Practice Address - State:GA
Practice Address - Zip Code:30134-6935
Practice Address - Country:US
Practice Address - Phone:678-838-9336
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-04-15
Last Update Date:2015-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALPC003228251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health