Provider Demographics
NPI:1467990119
Name:INTROSPECTION & REFLECTION
Entity Type:Organization
Organization Name:INTROSPECTION & REFLECTION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DAYSHA
Authorized Official - Middle Name:
Authorized Official - Last Name:PHIMPHONE
Authorized Official - Suffix:
Authorized Official - Credentials:LPC
Authorized Official - Phone:912-346-5344
Mailing Address - Street 1:184 HAMILTON GROVE DRIVE
Mailing Address - Street 2:
Mailing Address - City:POOLER
Mailing Address - State:GA
Mailing Address - Zip Code:31322
Mailing Address - Country:US
Mailing Address - Phone:912-346-5344
Mailing Address - Fax:
Practice Address - Street 1:184 HAMILTON GROVE DR
Practice Address - Street 2:
Practice Address - City:POOLER
Practice Address - State:GA
Practice Address - Zip Code:31322-9644
Practice Address - Country:US
Practice Address - Phone:912-346-5344
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-02-02
Last Update Date:2017-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA009203251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health