Provider Demographics
NPI:1083042105
Name:PSYCHIATRIC CONSULTING SERVICES OF SOUTH GEORGIA, LLC
Entity Type:Organization
Organization Name:PSYCHIATRIC CONSULTING SERVICES OF SOUTH GEORGIA, LLC
Other - Org Name:RENEWED MIND PSYCHIATRY AND COUNSELING
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:WENDY
Authorized Official - Middle Name:LIANA
Authorized Official - Last Name:VANDEMARK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:229-232-4833
Mailing Address - Street 1:2109 N PATTERSON ST STE B
Mailing Address - Street 2:
Mailing Address - City:VALDOSTA
Mailing Address - State:GA
Mailing Address - Zip Code:31602-2577
Mailing Address - Country:US
Mailing Address - Phone:229-232-4833
Mailing Address - Fax:877-343-0538
Practice Address - Street 1:2109 N PATTERSON ST STE B
Practice Address - Street 2:
Practice Address - City:VALDOSTA
Practice Address - State:GA
Practice Address - Zip Code:31602-2577
Practice Address - Country:US
Practice Address - Phone:229-232-4833
Practice Address - Fax:877-343-0538
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-10-29
Last Update Date:2024-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Single Specialty
No363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Multi-Specialty