Provider Demographics
NPI:1467562827
Name:SWEETWATER PSYCHOLOGICAL ASSOCIATES, LLC
Entity Type:Organization
Organization Name:SWEETWATER PSYCHOLOGICAL ASSOCIATES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER PARTNER
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:C
Authorized Official - Last Name:MARTIN
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:770-732-0982
Mailing Address - Street 1:PO BOX 1078
Mailing Address - Street 2:
Mailing Address - City:LITHIA SPRINGS
Mailing Address - State:GA
Mailing Address - Zip Code:30122-7078
Mailing Address - Country:US
Mailing Address - Phone:770-732-0982
Mailing Address - Fax:770-732-1283
Practice Address - Street 1:560 THORNTON RD
Practice Address - Street 2:SUITE 106
Practice Address - City:LITHIA SPRINGS
Practice Address - State:GA
Practice Address - Zip Code:30122-1655
Practice Address - Country:US
Practice Address - Phone:770-732-0982
Practice Address - Fax:770-732-1283
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-30
Last Update Date:2007-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPSY001373, PSY001157103T00000X, 103TC2200X
GAPSY001373103TB0200X
GAPSY001157103TB0200X
GAPSY001373,PSY001157103TC0700X
GACSW0007291041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Multi-Specialty
No103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Multi-Specialty
No103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & BehavioralGroup - Multi-Specialty
No103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & AdolescentGroup - Multi-Specialty
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAGRP2778Medicare PIN