Provider Demographics
NPI:1164870408
Name:SOUTHERN PSYCHOLOGICAL AND BEHAVIORAL SERVICES, LLC
Entity Type:Organization
Organization Name:SOUTHERN PSYCHOLOGICAL AND BEHAVIORAL SERVICES, LLC
Other - Org Name:SPBS
Other - Org Type:Other Name
Authorized Official - Title/Position:LICENSED PSYCHOLOGIST/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:TWYLA
Authorized Official - Middle Name:LUCINDA
Authorized Official - Last Name:MANCIL
Authorized Official - Suffix:
Authorized Official - Credentials:PH D
Authorized Official - Phone:352-727-8679
Mailing Address - Street 1:202 W GORDON ST
Mailing Address - Street 2:SUITE D
Mailing Address - City:VALDOSTA
Mailing Address - State:GA
Mailing Address - Zip Code:31601-4569
Mailing Address - Country:US
Mailing Address - Phone:229-474-9800
Mailing Address - Fax:229-515-4443
Practice Address - Street 1:202 W GORDON ST
Practice Address - Street 2:SUITE D
Practice Address - City:VALDOSTA
Practice Address - State:GA
Practice Address - Zip Code:31601-4569
Practice Address - Country:US
Practice Address - Phone:229-474-9800
Practice Address - Fax:229-515-4443
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-05-26
Last Update Date:2016-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPSY003935103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00316809AMedicaid