Provider Demographics
NPI:1689198194
Name:PEDIATRIC AUTISM CLINICAL & EVALUATION SERVICES LLC
Entity Type:Organization
Organization Name:PEDIATRIC AUTISM CLINICAL & EVALUATION SERVICES LLC
Other - Org Name:P.A.C.E.S., LLC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PSYCHOLOGIST/PARTNER
Authorized Official - Prefix:DR
Authorized Official - First Name:STEPHANIE
Authorized Official - Middle Name:ANNE
Authorized Official - Last Name:NORTHINGTON
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:706-842-3272
Mailing Address - Street 1:2945 WALTON WAY
Mailing Address - Street 2:
Mailing Address - City:AUGUSTA
Mailing Address - State:GA
Mailing Address - Zip Code:30909-3827
Mailing Address - Country:US
Mailing Address - Phone:706-842-3272
Mailing Address - Fax:706-842-3272
Practice Address - Street 1:2945 WALTON WAY
Practice Address - Street 2:
Practice Address - City:AUGUSTA
Practice Address - State:GA
Practice Address - Zip Code:30909-3827
Practice Address - Country:US
Practice Address - Phone:706-842-3279
Practice Address - Fax:706-842-3272
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-07-27
Last Update Date:2021-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA103K00000X, 103TC0700X, 106S00000X, 235Z00000X
225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Multi-Specialty
No103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Multi-Specialty
No106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Multi-Specialty
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Multi-Specialty
No235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA1457632150OtherPSYCHOLOGY
GA1386012573OtherOCCUPATIONAL THERAPY
GA1700123163OtherSPEECH THERAPY