Provider Demographics
NPI:1093978728
Name:SOUTHEASTERN PSYCHOLOGICAL CONSULTANT
Entity Type:Organization
Organization Name:SOUTHEASTERN PSYCHOLOGICAL CONSULTANT
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT PSYCHOLOGIST
Authorized Official - Prefix:DR
Authorized Official - First Name:SCOTT
Authorized Official - Middle Name:J
Authorized Official - Last Name:STEWART
Authorized Official - Suffix:
Authorized Official - Credentials:PH D
Authorized Official - Phone:706-325-0820
Mailing Address - Street 1:7362 EAGLE CT.
Mailing Address - Street 2:
Mailing Address - City:MIDLAND
Mailing Address - State:GA
Mailing Address - Zip Code:31820-4334
Mailing Address - Country:US
Mailing Address - Phone:706-325-0820
Mailing Address - Fax:706-568-1948
Practice Address - Street 1:7362 EAGLE CT
Practice Address - Street 2:
Practice Address - City:MIDLAND
Practice Address - State:GA
Practice Address - Zip Code:31820-4334
Practice Address - Country:US
Practice Address - Phone:706-325-0820
Practice Address - Fax:706-568-1948
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-07-02
Last Update Date:2008-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA2505103G00000X, 103T00000X
AL711103G00000X, 103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Multi-Specialty
No103G00000XBehavioral Health & Social Service ProvidersClinical NeuropsychologistGroup - Multi-Specialty