Provider Demographics
NPI:1326653783
Name:IVYDALE WELLNESS CENTER LLC
Entity Type:Organization
Organization Name:IVYDALE WELLNESS CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PMHNP-C
Authorized Official - Prefix:DR
Authorized Official - First Name:ABLAVI
Authorized Official - Middle Name:ADODO
Authorized Official - Last Name:AGOMESSOU
Authorized Official - Suffix:
Authorized Official - Credentials:NP
Authorized Official - Phone:404-819-8701
Mailing Address - Street 1:881 IVYDALE LN
Mailing Address - Street 2:
Mailing Address - City:LAWRENCEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30045-7818
Mailing Address - Country:US
Mailing Address - Phone:404-819-8701
Mailing Address - Fax:
Practice Address - Street 1:361 RESOURCE PKWY
Practice Address - Street 2:
Practice Address - City:WINDER
Practice Address - State:GA
Practice Address - Zip Code:30680-8364
Practice Address - Country:US
Practice Address - Phone:770-291-0419
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:19137243
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2020-09-12
Last Update Date:2020-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes251S00000XAgenciesCommunity/Behavioral Health
No261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary CareGroup - Single Specialty
No364SP0813XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistPsychiatric/Mental Health, GeropsychiatricGroup - Single Specialty