Provider Demographics
NPI:1376815563
Name:DONALDSON, JUSTIN (PHD)
Entity Type:Individual
Prefix:DR
First Name:JUSTIN
Middle Name:
Last Name:DONALDSON
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 1:315 W PONCE DE LEON AVE
Mailing Address - Street 2:SUITE 1064
Mailing Address - City:DECATUR
Mailing Address - State:GA
Mailing Address - Zip Code:30030-2400
Mailing Address - Country:US
Mailing Address - Phone:404-654-3411
Mailing Address - Fax:
Practice Address - Street 1:315 W PONCE DE LEON AVE
Practice Address - Street 2:SUITE 1064
Practice Address - City:DECATUR
Practice Address - State:GA
Practice Address - Zip Code:30030-2400
Practice Address - Country:US
Practice Address - Phone:404-654-3411
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-02-02
Last Update Date:2012-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA003538103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical