Provider Demographics
NPI:1114251188
Name:ROSWELL PSYCHIATRIC SERVICES, PC
Entity Type:Organization
Organization Name:ROSWELL PSYCHIATRIC SERVICES, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CONSUELO
Authorized Official - Middle Name:
Authorized Official - Last Name:REDDICK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:770-552-4655
Mailing Address - Street 1:PO BOX 1988
Mailing Address - Street 2:
Mailing Address - City:ROSWELL
Mailing Address - State:GA
Mailing Address - Zip Code:30077-1988
Mailing Address - Country:US
Mailing Address - Phone:770-552-4655
Mailing Address - Fax:770-552-4282
Practice Address - Street 1:77 E CROSSVILLE RD
Practice Address - Street 2:STE. 206
Practice Address - City:ROSWELL
Practice Address - State:GA
Practice Address - Zip Code:30075-5815
Practice Address - Country:US
Practice Address - Phone:770-552-4655
Practice Address - Fax:770-552-4282
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-09-24
Last Update Date:2009-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA0440672084P0800X, 2084P0804X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent PsychiatryGroup - Multi-Specialty
No2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAC75884Medicare UPIN