Provider Demographics
NPI:1225338577
Name:PROFESSIONAL ASSOCIATES HEALTH CARE OF GEORGIA
Entity Type:Organization
Organization Name:PROFESSIONAL ASSOCIATES HEALTH CARE OF GEORGIA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:STAFF
Authorized Official - Prefix:
Authorized Official - First Name:AGNEAU
Authorized Official - Middle Name:
Authorized Official - Last Name:JEAN-SIMON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:770-865-5073
Mailing Address - Street 1:316 S 9TH ST
Mailing Address - Street 2:
Mailing Address - City:GRIFFIN
Mailing Address - State:GA
Mailing Address - Zip Code:30224-4159
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:310 IVANHOE DR
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30215-2041
Practice Address - Country:US
Practice Address - Phone:770-461-9228
Practice Address - Fax:770-461-9228
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-11-02
Last Update Date:2024-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA932102913251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health