Provider Demographics
NPI:1134310980
Name:SUMMITRIDGE
Entity Type:Organization
Organization Name:SUMMITRIDGE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ASSESSMENT CSLR
Authorized Official - Prefix:MR
Authorized Official - First Name:MATTHEW
Authorized Official - Middle Name:
Authorized Official - Last Name:CAUDILL
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:678-312-5850
Mailing Address - Street 1:250 SCENIC HWY
Mailing Address - Street 2:
Mailing Address - City:LAWRENCEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30045-5675
Mailing Address - Country:US
Mailing Address - Phone:678-312-3585
Mailing Address - Fax:678-312-5915
Practice Address - Street 1:250 SCENIC HWY
Practice Address - Street 2:
Practice Address - City:LAWRENCEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30045-5675
Practice Address - Country:US
Practice Address - Phone:678-312-3585
Practice Address - Fax:678-312-5915
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-07
Last Update Date:2007-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes283Q00000XHospitalsPsychiatric Hospital