Provider Demographics
NPI:1871188771
Name:SOUTHEAST PSYCH SERVICES LLC
Entity Type:Organization
Organization Name:SOUTHEAST PSYCH SERVICES LLC
Other - Org Name:INTEGRATED PSYCH SOLUTIONS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:HETAL
Authorized Official - Middle Name:
Authorized Official - Last Name:THAKORE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:706-267-7681
Mailing Address - Street 1:1265 INTERSTATE PKWY STE B
Mailing Address - Street 2:
Mailing Address - City:AUGUSTA
Mailing Address - State:GA
Mailing Address - Zip Code:30909-6481
Mailing Address - Country:US
Mailing Address - Phone:706-204-1366
Mailing Address - Fax:
Practice Address - Street 1:561 FIELDCREST DR
Practice Address - Street 2:
Practice Address - City:THE VILLAGES
Practice Address - State:FL
Practice Address - Zip Code:32162-4600
Practice Address - Country:US
Practice Address - Phone:523-097-4653
Practice Address - Fax:855-264-6670
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-03-03
Last Update Date:2023-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Multi-Specialty
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty