Provider Demographics
NPI:1427569185
Name:GEORGIA PSYCHOLOGICAL TREATMENT CENTER LLC
Entity Type:Organization
Organization Name:GEORGIA PSYCHOLOGICAL TREATMENT CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PSYCHOLOGIST
Authorized Official - Prefix:DR
Authorized Official - First Name:LYDIA
Authorized Official - Middle Name:
Authorized Official - Last Name:ODENAT
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:678-687-9149
Mailing Address - Street 1:1777 WALKER RIDGE DR SW
Mailing Address - Street 2:
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30064-4192
Mailing Address - Country:US
Mailing Address - Phone:678-687-9149
Mailing Address - Fax:
Practice Address - Street 1:1640 POWERS FERRY RD SE
Practice Address - Street 2:
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30067-5491
Practice Address - Country:US
Practice Address - Phone:770-575-1696
Practice Address - Fax:404-891-6467
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-10-20
Last Update Date:2017-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty