Provider Demographics
NPI:1467805747
Name:PEACHTREE PSYCHOLOGY
Entity Type:Organization
Organization Name:PEACHTREE PSYCHOLOGY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LPC
Authorized Official - Prefix:
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:
Authorized Official - Last Name:KEENAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:617-206-3976
Mailing Address - Street 1:555 SUN VALLEY DR
Mailing Address - Street 2:P4
Mailing Address - City:ROSWELL
Mailing Address - State:GA
Mailing Address - Zip Code:30076-5612
Mailing Address - Country:US
Mailing Address - Phone:678-381-1687
Mailing Address - Fax:
Practice Address - Street 1:555 SUN VALLEY DR
Practice Address - Street 2:P4
Practice Address - City:ROSWELL
Practice Address - State:GA
Practice Address - Zip Code:30076-5612
Practice Address - Country:US
Practice Address - Phone:678-381-1687
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-07-21
Last Update Date:2016-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA003161101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003161OtherLICENSE