Provider Demographics
NPI:1790992360
Name:PSYCHOLOGICAL SERVICES OF COASTAL GEORGIA, PC
Entity Type:Organization
Organization Name:PSYCHOLOGICAL SERVICES OF COASTAL GEORGIA, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PSYCHOLOGIST
Authorized Official - Prefix:DR
Authorized Official - First Name:BRENDA
Authorized Official - Middle Name:SUE
Authorized Official - Last Name:RICHARDSON
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:912-756-5696
Mailing Address - Street 1:PO BOX 970
Mailing Address - Street 2:
Mailing Address - City:RICHMOND HILL
Mailing Address - State:GA
Mailing Address - Zip Code:31324-0970
Mailing Address - Country:US
Mailing Address - Phone:912-756-5696
Mailing Address - Fax:912-756-5636
Practice Address - Street 1:10375 FORD AVE STE 2
Practice Address - Street 2:
Practice Address - City:RICHMOND HILL
Practice Address - State:GA
Practice Address - Zip Code:31324-8811
Practice Address - Country:US
Practice Address - Phone:912-756-5696
Practice Address - Fax:912-756-5636
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-16
Last Update Date:2016-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA0931103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA68BBDLRMedicare ID - Type Unspecified