Provider Demographics
NPI:1093802233
Name:PSYCHOLOGICAL CONSULTANTS OF MARIETTA, PC
Entity Type:Organization
Organization Name:PSYCHOLOGICAL CONSULTANTS OF MARIETTA, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:MANFRED
Authorized Official - Last Name:ROLAND
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:770-420-9448
Mailing Address - Street 1:600 KENNESAW AVE NW
Mailing Address - Street 2:SUITE 300
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30060-6988
Mailing Address - Country:US
Mailing Address - Phone:770-420-9448
Mailing Address - Fax:
Practice Address - Street 1:600 KENNESAW AVE NW
Practice Address - Street 2:SUITE 300
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30060-6988
Practice Address - Country:US
Practice Address - Phone:770-420-9448
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-09
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA1872103TC0700X
GA897106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty
Not Answered106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00661691AMedicaid
GA00661691AMedicaid
GAS03937Medicare UPIN