Psych Practice LLC

Primary specialty

Community/Behavioral Health AgencyTaxonomy code 251S00000X

License

054327 Issued in GA

Legal business name

PSYCH PRACTICE LLC

Practice address

410 Shirley Ave
Douglas, GA 31533-2002

Phone

(912) 260-1206

Fax

(912) 383-7820

NPI assigned

Apr 15, 2015

Organization subpart

No

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

Authorized official

Name

Mr. Mubbashir M Khan, M.D

Title

Ceo/ M.D

Phone

(912) 260-1206

Specialties & licenses 1

Addresses

Other identifiers 1

Locations

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

{
    "created_epoch": "1429056000000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1429056000000",
    "number": "1689060790",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "410 SHIRLEY AVE",
            "city": "DOUGLAS",
            "state": "GA",
            "postal_code": "315332002",
            "telephone_number": "912-260-1206",
            "fax_number": "912-383-7820"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "410 SHIRLEY AVE",
            "city": "DOUGLAS",
            "state": "GA",
            "postal_code": "315332002",
            "telephone_number": "912-260-1206",
            "fax_number": "912-383-7820"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "PSYCH PRACTICE LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2015-04-15",
        "last_updated": "2015-04-15",
        "status": "A",
        "authorized_official_last_name": "KHAN",
        "authorized_official_first_name": "MUBBASHIR",
        "authorized_official_middle_name": "M",
        "authorized_official_title_or_position": "CEO/ M.D",
        "authorized_official_telephone_number": "912-260-1206",
        "authorized_official_name_prefix": "Mr.",
        "authorized_official_credential": "M.D"
    },
    "taxonomies": [
        {
            "code": "251S00000X",
            "taxonomy_group": "",
            "desc": "Community/Behavioral Health",
            "state": "GA",
            "license": "054327",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "003120037D",
            "state": "GA"
        }
    ],
    "endpoints": [],
    "other_names": []
}

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• Community/Behavioral Health Agency in Georgia

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Apr 15, 2015; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.