| Supportive Care of Georgia LLC | |
|
300 Colonial Center Pkwy Ste 100n Roswell GA 30076-4892 | |
| (718) 298-4375 | |
| Not Available |
| Full Name | Supportive Care of Georgia LLC |
|---|---|
| Speciality | Psychologist |
| Location | 300 Colonial Center Pkwy Ste 100n, Roswell, Georgia |
| Authorized Official Name and Position | Raphael Lichtschein (PRESIDENT) |
| Authorized Official Contact | 7182984375 |
| Accepts Medicare Insurance | Yes. This clinic participates in medicare program and accept medicare insurance. |
| Mailing Address | Practice Location Address |
|---|---|
| Supportive Care of Georgia LLC 27 Randolph Rd Howell NJ 07731-8611 Ph: (718) 298-4375 | Supportive Care of Georgia LLC 300 Colonial Center Pkwy Ste 100n Roswell GA 30076-4892 Ph: (718) 298-4375 |
| NPI Number | 1891362877 |
|---|---|
| Provider Enumeration Date | 06/08/2021 |
| Last Update Date | 06/08/2021 |
| Certification Date | 06/08/2021 |
| Medicare PECOS PAC ID | 9638573132 |
|---|---|
| Medicare Enrollment ID | O20210805001266 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1891362877 | NPI | - | NPPES |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 103TC0700X | Psychologist - Clinical | () | Primary |
| Provider Name | Robert Glenn |
|---|---|
| Provider Type | Practitioner - Psychiatry |
| Provider Identifiers | NPI Number: 1902033210 PECOS PAC ID: 9335328467 Enrollment ID: I20110121000519 |
| Provider Name | Sebrina Russell |
|---|---|
| Provider Type | Practitioner - Clinical Social Worker |
| Provider Identifiers | NPI Number: 1285266734 PECOS PAC ID: 1658741376 Enrollment ID: I20221221000899 |
| Provider Name | Contessa Metcalfe |
|---|---|
| Provider Type | Practitioner - Psychiatry |
| Provider Identifiers | NPI Number: 1639133135 PECOS PAC ID: 3072950211 Enrollment ID: I20260608004032 |
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