Provider Demographics
NPI:1073994182
Name:PATHWAYS CENTER FOR BEHAVIORAL AND DEVELOPMENTAL GROWTH
Entity Type:Organization
Organization Name:PATHWAYS CENTER FOR BEHAVIORAL AND DEVELOPMENTAL GROWTH
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:TRACY
Authorized Official - Middle Name:
Authorized Official - Last Name:HART
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:706-845-4045
Mailing Address - Street 1:122 GORDON COMMERCIAL DR STE C
Mailing Address - Street 2:
Mailing Address - City:LAGRANGE
Mailing Address - State:GA
Mailing Address - Zip Code:30240-5754
Mailing Address - Country:US
Mailing Address - Phone:706-845-4045
Mailing Address - Fax:706-845-4367
Practice Address - Street 1:102 CORPORATE PARK DRIVE EAST
Practice Address - Street 2:
Practice Address - City:LAGRANGE
Practice Address - State:GA
Practice Address - Zip Code:30241
Practice Address - Country:US
Practice Address - Phone:706-298-7800
Practice Address - Fax:706-298-7850
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PATHWAYS CENTER FOR BEHAVIORAL AND DEVELOPMENTAL GROWTH
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2015-06-15
Last Update Date:2015-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000599332CHMedicaid