Basic Information
| Provider Information | |||||||||
| NPI: | 1295246635 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SOUTHERN PSYCHIATRIC PROFESSIONALS, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 48 MAIN ST STE 2A | ||||||||
| Address2: | |||||||||
| City: | SENOIA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 302761895 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7704009660 | ||||||||
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| Practice Location | |||||||||
| Address1: | 48 MAIN ST STE 2A | ||||||||
| Address2: | |||||||||
| City: | SENOIA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 302761895 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7704009660 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/12/2017 | ||||||||
| LastUpdateDate: | 10/12/2017 | ||||||||
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| AuthorizedOfficialLastName: | SAVAGE | ||||||||
| AuthorizedOfficialFirstName: | SHANE | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRESIDENT/COO | ||||||||
| AuthorizedOfficialTelephone: | 7704009660 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM0801X | Y | Ambulatory Health Care Facilities | Clinic/Center | Mental Health (Including Community Mental Health Center) |
No ID Information.