NPIMap

Organization Active NPI

Southeastern Psychological Associates, Inc

  • Clinical Child & Adolescent Psychologist
  • Covington, GA
National Provider Identifier
1316216880
Registry record updated May 3, 2017
On this page

Key facts

NPPES NPI Registry
Primary specialty
Clinical Child & Adolescent PsychologistTaxonomy code 103TC2200X
License
PSY002144 Issued in GA
Legal business name
SOUTHEASTERN PSYCHOLOGICAL ASSOCIATES, INC
Practice address
3155 Mill Street
Covington, GA 30014
Phone
(404) 226-0939
Fax
(678) 802-0939
NPI assigned
Dec 29, 2011
Organization subpart
No

NPPES NPI Registry

Updated by the provider on May 3, 2017

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Dr. Priscilla Faulkner, PSYDNPI 1366579773
Title
Owner/Director
Phone
(678) 712-6520

Authorized official NPPES reports the official by name only. The link goes to the one practitioner connected to this organization with that name.

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Clinical Child & Adolescent PsychologistGroup: 193200000X MULTI-SPECIALTY GROUP 103TC2200X PSY002144 GA Primary

Addresses

Primary practice location

3155 Mill Street
Covington, GA 30014

Mailing address

3155 Mill Street
Covington, GA 30014-2542
Phone (678) 712-6520

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in GA

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20120405000302 GA Part B Supplier - Clinic/Group Practice 9537320254 Receives reassigned benefits from 4 practitioners
Practice locations: Covington, GA

National Provider Directory

National Provider Directory

Locations

3155 Mill St NE
Covington, GA 30014
Phone (678) 712-6520

Practitioners & affiliated clinicians

Practitioners 16

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

View all 16

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1325116800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1493769600000",
    "number": "1316216880",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "3155 MILL STREET",
            "city": "COVINGTON",
            "state": "GA",
            "postal_code": "300142542",
            "telephone_number": "678-712-6520",
            "fax_number": "678-712-6521"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "3155 MILL STREET",
            "city": "COVINGTON",
            "state": "GA",
            "postal_code": "30014",
            "telephone_number": "404-226-0939",
            "fax_number": "678-802-0939"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "SOUTHEASTERN PSYCHOLOGICAL ASSOCIATES, INC",
        "organizational_subpart": "NO",
        "enumeration_date": "2011-12-29",
        "last_updated": "2017-05-03",
        "status": "A",
        "authorized_official_last_name": "FAULKNER",
        "authorized_official_first_name": "PRISCILLA",
        "authorized_official_title_or_position": "OWNER/DIRECTOR",
        "authorized_official_telephone_number": "678-712-6520",
        "authorized_official_name_prefix": "Dr.",
        "authorized_official_credential": "PSYD"
    },
    "taxonomies": [
        {
            "code": "103TC2200X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Psychologist, Clinical Child & Adolescent",
            "state": "GA",
            "license": "PSY002144",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

Other providers in Covington, GA

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on May 3, 2017; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.