Organization
PSYCHOLOGICAL AFFILIATES
Active
Organization subpart
No
Provider details
NPI number
Authorized official
JACK HOLLAND GRISHAM PH.D. (PRESIDENT)
(770) 427-2911
Entity
Organization
Contact information
Practice address
122 CHERRY ST NE, MARIETTA, GA 30060-7206
(770) 427-2911
Mailing address
122 CHERRY ST NE, MARIETTA, GA 30060-7206
(770) 427-2911
Taxonomy
Speciality
Code
Description
License number
State
103T00000X
Psychologist
Primary
000669 GA
GA
1041C0700X
Clinical Social Worker
001135 GA
GA
1041C0700X
Clinical Social Worker
GA CSW003681
GA
Other
Enumeration date
01/09/2008
Last updated
01/09/2008
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