Provider Demographics
NPI:1346318284
Name:AYCOCK, DAVID WAYNE (PHD)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:WAYNE
Last Name:AYCOCK
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:115 HABERSHAM DR
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30214
Mailing Address - Country:US
Mailing Address - Phone:770-461-9944
Mailing Address - Fax:770-461-9779
Practice Address - Street 1:115 HABERSHAM DR
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30214
Practice Address - Country:US
Practice Address - Phone:770-461-9944
Practice Address - Fax:770-461-9779
Is Sole Proprietor?:No
Enumeration Date:2006-11-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPSY1239103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00440349BMedicaid
GA680015333OtherRAILROAD MEDICARE
GA680015333OtherRAILROAD MEDICARE
R70748Medicare UPIN