Provider Demographics
NPI:1427405554
Name:PSYCHOLOGICAL DIAGNOSTIC CENTER, LLC
Entity Type:Organization
Organization Name:PSYCHOLOGICAL DIAGNOSTIC CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LICENSED PSYCHOLOGIST
Authorized Official - Prefix:DR
Authorized Official - First Name:WILLA
Authorized Official - Middle Name:L
Authorized Official - Last Name:BOSTON
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD
Authorized Official - Phone:770-953-4744
Mailing Address - Street 1:1827 POWERS FERRY RD
Mailing Address - Street 2:BUILDING 22, SUITE 200
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30339
Mailing Address - Country:US
Mailing Address - Phone:770-953-4744
Mailing Address - Fax:770-953-4640
Practice Address - Street 1:3860 WINDERMERE PKWY
Practice Address - Street 2:UNIT 203
Practice Address - City:CUMMING
Practice Address - State:GA
Practice Address - Zip Code:30041-7005
Practice Address - Country:US
Practice Address - Phone:770-953-4744
Practice Address - Fax:770-953-4640
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-05-18
Last Update Date:2016-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPSY003953103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003169841AMedicaid
GA202I629735Medicare PIN