Provider Demographics
NPI:1114483534
Name:BETAN, EPHI J (PHD)
Entity Type:Individual
Prefix:DR
First Name:EPHI
Middle Name:J
Last Name:BETAN
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2200 CENTURY PKWY NE STE 200
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30345-3103
Mailing Address - Country:US
Mailing Address - Phone:404-422-5203
Mailing Address - Fax:
Practice Address - Street 1:2200 CENTURY PKWY NE STE 200
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30345-3103
Practice Address - Country:US
Practice Address - Phone:404-422-5203
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-02-11
Last Update Date:2022-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPSY002608103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist