Provider Demographics
NPI:1366596025
Name:AUSBORN, WILLIE F (PSYD)
Entity type:Individual
Prefix:DR
First Name:WILLIE
Middle Name:F
Last Name:AUSBORN
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4500 HUGH HOWELL RD
Mailing Address - Street 2:SUITE 740
Mailing Address - City:TUCKER
Mailing Address - State:GA
Mailing Address - Zip Code:30084-4723
Mailing Address - Country:US
Mailing Address - Phone:770-938-4616
Mailing Address - Fax:770-938-4615
Practice Address - Street 1:4500 HUGH HOWELL RD
Practice Address - Street 2:SUITE 740
Practice Address - City:TUCKER
Practice Address - State:GA
Practice Address - Zip Code:30084-4723
Practice Address - Country:US
Practice Address - Phone:770-938-4616
Practice Address - Fax:770-938-4615
Is Sole Proprietor?:No
Enumeration Date:2007-01-22
Last Update Date:2009-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA2449103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAA3022OtherKAISER
GA01000298OtherAMERIGROUP
GA000885629AOtherCENPATICO
GA000885629AMedicaid
GA001346OtherBLUECROSS BLUESHIELD
GA33-1078488OtherNORTHLAKE MEDICAL RESEARC
GAA3022OtherKAISER