Provider Demographics
NPI:1639439201
Name:LIVING FULLY PSYCHOLOGICAL SERVICES, LLC
Entity Type:Organization
Organization Name:LIVING FULLY PSYCHOLOGICAL SERVICES, LLC
Other - Org Name:PEGAH MOGHADDAM, PSY.D.
Other - Org Type:Other Name
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:PEGAH
Authorized Official - Middle Name:
Authorized Official - Last Name:MOGHADDAM
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD
Authorized Official - Phone:678-591-9117
Mailing Address - Street 1:111 N MCDONOUGH ST
Mailing Address - Street 2:
Mailing Address - City:DECATUR
Mailing Address - State:GA
Mailing Address - Zip Code:30030-3317
Mailing Address - Country:US
Mailing Address - Phone:678-591-9117
Mailing Address - Fax:770-458-8640
Practice Address - Street 1:111 N MCDONOUGH ST
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:GA
Practice Address - Zip Code:30030-3317
Practice Address - Country:US
Practice Address - Phone:678-591-9117
Practice Address - Fax:770-458-8640
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-05-17
Last Update Date:2013-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPSY003405103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Multi-Specialty