Provider Demographics
NPI:1457627044
Name:ATHENS PSYCHOLOGICAL SERVICES, LLC
Entity Type:Organization
Organization Name:ATHENS PSYCHOLOGICAL SERVICES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:JOSEPH
Authorized Official - Middle Name:E
Authorized Official - Last Name:MASON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:706-548-8697
Mailing Address - Street 1:1090 FOUNDERS BLVD
Mailing Address - Street 2:STE. B
Mailing Address - City:ATHENS
Mailing Address - State:GA
Mailing Address - Zip Code:30606-6163
Mailing Address - Country:US
Mailing Address - Phone:706-548-8697
Mailing Address - Fax:706-548-8698
Practice Address - Street 1:1090 FOUNDERS BLVD
Practice Address - Street 2:STE. B
Practice Address - City:ATHENS
Practice Address - State:GA
Practice Address - Zip Code:30606-6163
Practice Address - Country:US
Practice Address - Phone:706-548-8697
Practice Address - Fax:706-548-8698
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-03-28
Last Update Date:2012-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPSY002674103T00000X, 103TB0200X, 103TC2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & AdolescentGroup - Multi-Specialty
No103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Multi-Specialty
No103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & BehavioralGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA050836150CMedicaid
10034544OtherAMERIGROUP
556185000OtherMAGELLAN