Provider Demographics
NPI:1083779763
Name:PSYCHOGENESIS, INC.
Entity Type:Organization
Organization Name:PSYCHOGENESIS, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JUDITH
Authorized Official - Middle Name:
Authorized Official - Last Name:TUTIN
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:706-232-5544
Mailing Address - Street 1:2 WINDSOR RD SW
Mailing Address - Street 2:
Mailing Address - City:ROME
Mailing Address - State:GA
Mailing Address - Zip Code:30165-8555
Mailing Address - Country:US
Mailing Address - Phone:706-232-5544
Mailing Address - Fax:888-543-1173
Practice Address - Street 1:519 BROAD ST
Practice Address - Street 2:SUITE 202
Practice Address - City:ROME
Practice Address - State:GA
Practice Address - Zip Code:30161-1734
Practice Address - Country:US
Practice Address - Phone:706-232-5544
Practice Address - Fax:888-543-1173
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-24
Last Update Date:2015-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA2075103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000728923AMedicaid
GAGRP4896Medicare UPIN