Provider Demographics
NPI:1821429721
Name:CHL PSYCHOLOGY ASSOCIATES
Entity Type:Organization
Organization Name:CHL PSYCHOLOGY ASSOCIATES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LICENSED PSYCHOLOGIST
Authorized Official - Prefix:DR
Authorized Official - First Name:CAROLINE
Authorized Official - Middle Name:
Authorized Official - Last Name:LEAVITT
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:770-592-0150
Mailing Address - Street 1:1001 WEATHERSTONE PKWY
Mailing Address - Street 2:SUITE 430
Mailing Address - City:WOODSTOCK
Mailing Address - State:GA
Mailing Address - Zip Code:30188-4495
Mailing Address - Country:US
Mailing Address - Phone:770-592-0150
Mailing Address - Fax:770-592-0971
Practice Address - Street 1:1001 WEATHERSTONE PKWY
Practice Address - Street 2:SUITE 430
Practice Address - City:WOODSTOCK
Practice Address - State:GA
Practice Address - Zip Code:30188-4495
Practice Address - Country:US
Practice Address - Phone:770-592-0150
Practice Address - Fax:770-592-0971
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-12-03
Last Update Date:2013-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPSY003317261QM0850X, 261QM0855X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
No261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA502314641AMedicaid