Provider Demographics
NPI:1194013912
Name:DECATUR PSYCHOLOGY, LLC
Entity Type:Organization
Organization Name:DECATUR PSYCHOLOGY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:RACKLEY
Authorized Official - Last Name:LUCY
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:404-513-6077
Mailing Address - Street 1:101 BIRCH ST
Mailing Address - Street 2:
Mailing Address - City:DECATUR
Mailing Address - State:GA
Mailing Address - Zip Code:30030-3340
Mailing Address - Country:US
Mailing Address - Phone:404-513-6077
Mailing Address - Fax:404-478-6823
Practice Address - Street 1:101 BIRCH ST
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:GA
Practice Address - Zip Code:30030-3340
Practice Address - Country:US
Practice Address - Phone:404-513-6077
Practice Address - Fax:404-478-6823
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-07-13
Last Update Date:2021-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPSY001911103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA1134380322OtherINDIVIDUAL NPI