Provider Demographics
NPI:1093026601
Name:JOHN AZAR-DICKENS, PH.D.,PC
Entity Type:Organization
Organization Name:JOHN AZAR-DICKENS, PH.D.,PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LICENSED PSYCHOLOGIST
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:AZAR-DICKENS
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:706-234-0659
Mailing Address - Street 1:PO BOX 1008
Mailing Address - Street 2:
Mailing Address - City:ROME
Mailing Address - State:GA
Mailing Address - Zip Code:30162-1008
Mailing Address - Country:US
Mailing Address - Phone:706-232-6743
Mailing Address - Fax:
Practice Address - Street 1:109 JOHN MADDOX DR NW
Practice Address - Street 2:
Practice Address - City:ROME
Practice Address - State:GA
Practice Address - Zip Code:30165-1451
Practice Address - Country:US
Practice Address - Phone:706-232-6743
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-06-29
Last Update Date:2010-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA002459103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00895837JMedicaid