Provider Demographics
NPI:1538302864
Name:PSY-VISIONS OF GA, LLC
Entity Type:Organization
Organization Name:PSY-VISIONS OF GA, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PSYCHIATRIST/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:DOUGLAS
Authorized Official - Last Name:STRACKS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:706-885-0111
Mailing Address - Street 1:300 MEDICAL DR
Mailing Address - Street 2:SUITE 705
Mailing Address - City:LAGRANGE
Mailing Address - State:GA
Mailing Address - Zip Code:30240-4130
Mailing Address - Country:US
Mailing Address - Phone:706-885-0111
Mailing Address - Fax:706-885-0607
Practice Address - Street 1:300 MEDICAL DR
Practice Address - Street 2:SUITE 705
Practice Address - City:LAGRANGE
Practice Address - State:GA
Practice Address - Zip Code:30240-4130
Practice Address - Country:US
Practice Address - Phone:706-885-0111
Practice Address - Fax:706-885-0607
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-04-16
Last Update Date:2009-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA0603112084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA567393386AMedicaid