Provider Demographics
NPI:1578628087
Name:PSA HEALTHCARE
Entity Type:Organization
Organization Name:PSA HEALTHCARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SPEECH LANGUAGE PATHOLOGIST
Authorized Official - Prefix:MS
Authorized Official - First Name:THERESA
Authorized Official - Middle Name:
Authorized Official - Last Name:ROBINSON
Authorized Official - Suffix:
Authorized Official - Credentials:MS-CCC-SLP
Authorized Official - Phone:478-841-2772
Mailing Address - Street 1:770 BACONSFIELD DR
Mailing Address - Street 2:BUILDING 1
Mailing Address - City:MACON
Mailing Address - State:GA
Mailing Address - Zip Code:31211-1400
Mailing Address - Country:US
Mailing Address - Phone:478-841-2772
Mailing Address - Fax:478-841-2644
Practice Address - Street 1:770 BACONSFIELD DR
Practice Address - Street 2:BUILDING 1
Practice Address - City:MACON
Practice Address - State:GA
Practice Address - Zip Code:31211-1400
Practice Address - Country:US
Practice Address - Phone:478-841-2772
Practice Address - Fax:478-841-2644
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-26
Last Update Date:2008-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPT002429225100000X
GAPT002435225100000X
GAOT003589225X00000X
GASLP001909235Z00000X
GASLP005082235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Multi-Specialty
No235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000760702CMedicaid
GA000699784FMedicaid
GA000868238CMedicaid
GA000954665BMedicaid
GA000913844DMedicaid