Provider Demographics
NPI:1013328582
Name:HARGROVE, VERLYN GAIL
Entity Type:Individual
Prefix:MRS
First Name:VERLYN
Middle Name:GAIL
Last Name:HARGROVE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:277 MLK BLVD STE 203
Mailing Address - Street 2:
Mailing Address - City:MACON
Mailing Address - State:GA
Mailing Address - Zip Code:31201-3498
Mailing Address - Country:US
Mailing Address - Phone:478-745-2811
Mailing Address - Fax:478-745-0881
Practice Address - Street 1:106 OLYMPIA DR STE B
Practice Address - Street 2:
Practice Address - City:WARNER ROBINS
Practice Address - State:GA
Practice Address - Zip Code:31093-3614
Practice Address - Country:US
Practice Address - Phone:478-745-2811
Practice Address - Fax:478-745-0881
Is Sole Proprietor?:No
Enumeration Date:2014-05-18
Last Update Date:2014-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALPC005010101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003145652AMedicaid