Provider Demographics
NPI:1447842570
Name:AMETHYST PSYCHOLOGICAL SERVICES
Entity type:Organization
Organization Name:AMETHYST PSYCHOLOGICAL SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JASMINE
Authorized Official - Middle Name:
Authorized Official - Last Name:WINBUSH
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD
Authorized Official - Phone:470-223-5921
Mailing Address - Street 1:4617 IVYGATE CIR SE
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30339-1331
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1774 CENTURY BLVD NE STE B
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30345-3312
Practice Address - Country:US
Practice Address - Phone:470-223-5921
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-02-10
Last Update Date:2021-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA1073097168OtherINDIVIDUAL PROVIDER NPI