Provider Demographics
NPI:1457741829
Name:CARREFOUR OF ATLANTA PSYCHOLOGICAL HEALTH INSTITUTE LLC
Entity type:Organization
Organization Name:CARREFOUR OF ATLANTA PSYCHOLOGICAL HEALTH INSTITUTE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LICENSED PSYCHOLOGIST
Authorized Official - Prefix:DR
Authorized Official - First Name:LYDIA
Authorized Official - Middle Name:
Authorized Official - Last Name:ODENAT
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:678-687-9149
Mailing Address - Street 1:2465 MAIN ST UNIT 307
Mailing Address - Street 2:
Mailing Address - City:EAST POINT
Mailing Address - State:GA
Mailing Address - Zip Code:30344-2675
Mailing Address - Country:US
Mailing Address - Phone:678-687-9149
Mailing Address - Fax:
Practice Address - Street 1:2751 BUFORD HWY NE STE 700
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30324-3207
Practice Address - Country:US
Practice Address - Phone:678-687-9149
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-01-23
Last Update Date:2015-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPSY003854103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Single Specialty