Provider Demographics
NPI:1821272204
Name:ISRALSKY, MARC (PHD)
Entity Type:Individual
Prefix:DR
First Name:MARC
Middle Name:
Last Name:ISRALSKY
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:840 CHURCH ST NE
Mailing Address - Street 2:BUILDING F
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30060-8936
Mailing Address - Country:US
Mailing Address - Phone:770-428-8417
Mailing Address - Fax:770-565-3090
Practice Address - Street 1:840 CHURCH ST NE
Practice Address - Street 2:BUILDING F
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30060-8936
Practice Address - Country:US
Practice Address - Phone:770-428-8417
Practice Address - Fax:770-565-3090
Is Sole Proprietor?:Yes
Enumeration Date:2007-12-20
Last Update Date:2007-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA1090103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00341404AMedicaid