Provider Demographics
NPI:1225245202
Name:SIWY, JAMES M (PHD)
Entity Type:Individual
Prefix:
First Name:JAMES
Middle Name:M
Last Name:SIWY
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:390 N POND TRL
Mailing Address - Street 2:
Mailing Address - City:ROSWELL
Mailing Address - State:GA
Mailing Address - Zip Code:30076-2921
Mailing Address - Country:US
Mailing Address - Phone:770-641-7720
Mailing Address - Fax:770-642-7957
Practice Address - Street 1:555 SUN VALLEY DR
Practice Address - Street 2:SUITE L-4
Practice Address - City:ROSWELL
Practice Address - State:GA
Practice Address - Zip Code:30076-5612
Practice Address - Country:US
Practice Address - Phone:770-641-7720
Practice Address - Fax:770-642-7957
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-17
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPSY000989103TC0700X, 103TP2701X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Not Answered103TP2701XBehavioral Health & Social Service ProvidersPsychologistGroup Psychotherapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAR88779Medicare UPIN
GA68BBGQGMedicare ID - Type UnspecifiedGA MEDICARE PART B PIN