Provider Demographics
NPI:1093062606
Name:GRACE PSYCHOTHERAPY & PSYCHOLOGICAL ASSESMENT SERVICES OF NORTH GA
Entity Type:Organization
Organization Name:GRACE PSYCHOTHERAPY & PSYCHOLOGICAL ASSESMENT SERVICES OF NORTH GA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:F
Authorized Official - Last Name:GRACE
Authorized Official - Suffix:
Authorized Official - Credentials:PSY,D
Authorized Official - Phone:706-552-0450
Mailing Address - Street 1:1 HUNTINGTON RD
Mailing Address - Street 2:SUITE 801
Mailing Address - City:ATHENS
Mailing Address - State:GA
Mailing Address - Zip Code:30606-7204
Mailing Address - Country:US
Mailing Address - Phone:706-552-0450
Mailing Address - Fax:706-850-7211
Practice Address - Street 1:1 HUNTINGTON RD
Practice Address - Street 2:SUITE 801
Practice Address - City:ATHENS
Practice Address - State:GA
Practice Address - Zip Code:30606-7204
Practice Address - Country:US
Practice Address - Phone:706-552-0450
Practice Address - Fax:706-850-7211
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-08-14
Last Update Date:2012-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPSY003032103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA476047042AMedicaid