Provider Demographics
NPI:1588797799
Name:PATHWAYS CENTER FOR BEHAVIORAL AND DEVELOPMENTAL GROWTH
Entity Type:Organization
Organization Name:PATHWAYS CENTER FOR BEHAVIORAL AND DEVELOPMENTAL GROWTH
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:JADE
Authorized Official - Middle Name:RUSSELL
Authorized Official - Last Name:BENEFIELD
Authorized Official - Suffix:
Authorized Official - Credentials:MBA
Authorized Official - Phone:706-845-4045
Mailing Address - Street 1:122 GORDON COMMERCIAL DRIVE
Mailing Address - Street 2:SUITE C
Mailing Address - City:LAGRANGE
Mailing Address - State:GA
Mailing Address - Zip Code:30240-5740
Mailing Address - Country:US
Mailing Address - Phone:706-845-4045
Mailing Address - Fax:706-845-4367
Practice Address - Street 1:122 GORDON COMMERCIAL DRIVE
Practice Address - Street 2:SUITE C
Practice Address - City:LAGRANGE
Practice Address - State:GA
Practice Address - Zip Code:30240-5740
Practice Address - Country:US
Practice Address - Phone:706-845-4045
Practice Address - Fax:706-845-4367
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-14
Last Update Date:2015-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000599332ADMedicaid
GA000599332BMedicaid
GA000599332BEMedicaid
GA000599332AFMedicaid
GA000599332GMedicaid
GA000599332AJMedicaid
GA000599332LMedicaid
GA000599332TMedicaid
GA000599332ABMedicaid
GA000599332ACMedicaid
GA000599332AAMedicaid
GA000599332BFMedicaid
GA000599332EMedicaid
GA000599332NMedicaid
GA000599332YMedicaid
GA000599332AJMedicaid
GA000599332GMedicaid