Provider Demographics
NPI:1326317488
Name:PIONEER PSYCHOLOGICAL ASSOCIATES, LLC
Entity Type:Organization
Organization Name:PIONEER PSYCHOLOGICAL ASSOCIATES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL PSYCHOLOGIST
Authorized Official - Prefix:DR
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:
Authorized Official - Last Name:WACHTEL
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD
Authorized Official - Phone:404-723-5633
Mailing Address - Street 1:5605 GLENRIDGE DR NE
Mailing Address - Street 2:SUITE 600
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30342-1365
Mailing Address - Country:US
Mailing Address - Phone:404-723-5633
Mailing Address - Fax:
Practice Address - Street 1:5605 GLENRIDGE DR NE
Practice Address - Street 2:SUITE 600
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30342-1365
Practice Address - Country:US
Practice Address - Phone:404-723-5633
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-12-19
Last Update Date:2016-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPSY003012103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA68BBGVXMedicare Oscar/Certification