Provider Demographics
NPI:1194202911
Name:SAMUDRA PSYCHOLOGICAL SERVICES LLC
Entity Type:Organization
Organization Name:SAMUDRA PSYCHOLOGICAL SERVICES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LICENSED PSYCHOLOGIST
Authorized Official - Prefix:DR
Authorized Official - First Name:ELIZABETH
Authorized Official - Middle Name:SUE
Authorized Official - Last Name:BRADSHAW-LIVINGSTON
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:404-249-0520
Mailing Address - Street 1:316 SOMERLANE PL
Mailing Address - Street 2:
Mailing Address - City:AVONDALE ESTATES
Mailing Address - State:GA
Mailing Address - Zip Code:30002-1221
Mailing Address - Country:US
Mailing Address - Phone:269-352-7407
Mailing Address - Fax:
Practice Address - Street 1:675 SEMINOLE AVE NE STE T03
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30307-3409
Practice Address - Country:US
Practice Address - Phone:404-249-0520
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-07-24
Last Update Date:2018-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA003691261QM0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)