Provider Demographics
NPI:1720110398
Name:GWINNETT PSYCHIATRY, P.C.
Entity Type:Organization
Organization Name:GWINNETT PSYCHIATRY, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:NASIRA
Authorized Official - Middle Name:
Authorized Official - Last Name:RUBINA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:678-749-6063
Mailing Address - Street 1:170 CAMDEN HILL RD
Mailing Address - Street 2:SUITE C
Mailing Address - City:LAWRENCEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30046-7418
Mailing Address - Country:US
Mailing Address - Phone:678-226-2295
Mailing Address - Fax:678-226-2296
Practice Address - Street 1:170 CAMDEN HILL RD
Practice Address - Street 2:SUITE C
Practice Address - City:LAWRENCEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30046-7418
Practice Address - Country:US
Practice Address - Phone:678-226-2295
Practice Address - Fax:678-226-2296
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-09
Last Update Date:2012-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA056642261QM0850X, 261QM0855X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health
No261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA648074039AMedicaid
GA10068469Medicaid