Provider Demographics
NPI:1316216880
Name:SOUTHEASTERN PSYCHOLOGICAL ASSOCIATES, INC
Entity Type:Organization
Organization Name:SOUTHEASTERN PSYCHOLOGICAL ASSOCIATES, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:PRISCILLA
Authorized Official - Middle Name:
Authorized Official - Last Name:FAULKNER
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD
Authorized Official - Phone:678-712-6520
Mailing Address - Street 1:3155 MILL STREET
Mailing Address - Street 2:
Mailing Address - City:COVINGTON
Mailing Address - State:GA
Mailing Address - Zip Code:30014-2542
Mailing Address - Country:US
Mailing Address - Phone:678-712-6520
Mailing Address - Fax:678-712-6521
Practice Address - Street 1:3155 MILL STREET
Practice Address - Street 2:
Practice Address - City:COVINGTON
Practice Address - State:GA
Practice Address - Zip Code:30014
Practice Address - Country:US
Practice Address - Phone:404-226-0939
Practice Address - Fax:678-802-0939
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-12-29
Last Update Date:2017-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPSY002144103TC2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & AdolescentGroup - Multi-Specialty