Provider Demographics
NPI:1437214350
Name:REDDICK, CONSUELO (MD)
Entity Type:Individual
Prefix:
First Name:CONSUELO
Middle Name:
Last Name:REDDICK
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1988
Mailing Address - Street 2:
Mailing Address - City:ROSWELL
Mailing Address - State:GA
Mailing Address - Zip Code:30077-1988
Mailing Address - Country:US
Mailing Address - Phone:770-662-4655
Mailing Address - Fax:770-552-4282
Practice Address - Street 1:77 E CROSSVILLE RD
Practice Address - Street 2:STE. 206
Practice Address - City:ROSWELL
Practice Address - State:GA
Practice Address - Zip Code:30075-5815
Practice Address - Country:US
Practice Address - Phone:770-552-4655
Practice Address - Fax:770-552-4282
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-22
Last Update Date:2019-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA0440672084P0800X, 2084P0804X
CAG1330492084P0800X, 2084P0804X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent Psychiatry
No2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00024706Medicaid
GAC75884Medicare UPIN
GA26DGJHMedicare ID - Type Unspecified
GA00024706Medicaid