Provider Demographics
NPI:1689943748
Name:ALLISON, AVA GALE (CAC)
Entity Type:Individual
Prefix:MRS
First Name:AVA
Middle Name:GALE
Last Name:ALLISON
Suffix:
Gender:F
Credentials:CAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7753 LUTHERSVILLE RD
Mailing Address - Street 2:
Mailing Address - City:GAY
Mailing Address - State:GA
Mailing Address - Zip Code:30218-2003
Mailing Address - Country:US
Mailing Address - Phone:706-977-7465
Mailing Address - Fax:770-960-2024
Practice Address - Street 1:7753 LUTHERSVILLE RD
Practice Address - Street 2:
Practice Address - City:GAY
Practice Address - State:GA
Practice Address - Zip Code:30218-2003
Practice Address - Country:US
Practice Address - Phone:706-977-7465
Practice Address - Fax:770-960-2024
Is Sole Proprietor?:Yes
Enumeration Date:2011-12-19
Last Update Date:2011-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA1830101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)