Provider Demographics
NPI:1639290299
Name:NEUROSMART PSYCHOLOGICAL ASSOCIATES, P.C.
Entity Type:Organization
Organization Name:NEUROSMART PSYCHOLOGICAL ASSOCIATES, P.C.
Other - Org Name:NEUROSMART, INC.
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:KATHRYN
Authorized Official - Middle Name:C
Authorized Official - Last Name:BLACK
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:770-889-2848
Mailing Address - Street 1:309 PIRKLE FERRY RD
Mailing Address - Street 2:SUITE A-200
Mailing Address - City:CUMMING
Mailing Address - State:GA
Mailing Address - Zip Code:30040-2546
Mailing Address - Country:US
Mailing Address - Phone:770-889-2848
Mailing Address - Fax:
Practice Address - Street 1:309 PIRKLE FERRY RD
Practice Address - Street 2:SUITE A-200
Practice Address - City:CUMMING
Practice Address - State:GA
Practice Address - Zip Code:30040-2546
Practice Address - Country:US
Practice Address - Phone:770-889-2848
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-02
Last Update Date:2011-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA103G00000X, 103TC2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & AdolescentGroup - Multi-Specialty
No103G00000XBehavioral Health & Social Service ProvidersClinical NeuropsychologistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA614308690AMedicaid