Provider Demographics
NPI:1376059998
Name:GEORGIA AUTISM CENTER LLC
Entity Type:Organization
Organization Name:GEORGIA AUTISM CENTER LLC
Other - Org Name:JAYMIE HELEN LUCKOW FOX SOLE MBR
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JAYMIE
Authorized Official - Middle Name:L
Authorized Official - Last Name:FOX
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD
Authorized Official - Phone:770-696-4384
Mailing Address - Street 1:4046 WETHERBURN WAY STE 1
Mailing Address - Street 2:
Mailing Address - City:PEACHTREE CORNERS
Mailing Address - State:GA
Mailing Address - Zip Code:30092-4614
Mailing Address - Country:US
Mailing Address - Phone:770-696-4384
Mailing Address - Fax:
Practice Address - Street 1:4046 WETHERBURN WAY STE 1
Practice Address - Street 2:
Practice Address - City:PEACHTREE CORNERS
Practice Address - State:GA
Practice Address - Zip Code:30092-4614
Practice Address - Country:US
Practice Address - Phone:770-696-4384
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-12-19
Last Update Date:2017-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPSY2999103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA380415072CMedicaid