Provider Demographics
NPI:1225221492
Name:RICHARD BORN, PH.D. LLC
Entity Type:Organization
Organization Name:RICHARD BORN, PH.D. LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LICENSED PSYCHOLOGIST
Authorized Official - Prefix:
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:
Authorized Official - Last Name:BORN
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:706-543-7605
Mailing Address - Street 1:1 HUNTINGTON RD
Mailing Address - Street 2:#205
Mailing Address - City:ATHENS
Mailing Address - State:GA
Mailing Address - Zip Code:30606-7204
Mailing Address - Country:US
Mailing Address - Phone:706-543-7605
Mailing Address - Fax:706-543-2397
Practice Address - Street 1:1 HUNTINGTON RD
Practice Address - Street 2:#205
Practice Address - City:ATHENS
Practice Address - State:GA
Practice Address - Zip Code:30606-7204
Practice Address - Country:US
Practice Address - Phone:706-543-7605
Practice Address - Fax:706-543-2397
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-21
Last Update Date:2007-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPSY001283103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAGRP6651Medicare PIN