Provider Demographics
NPI:1295897254
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:
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 1:59 HOSPITAL RD
Practice Address - Street 2:
Practice Address - City:NEWNAN
Practice Address - State:GA
Practice Address - Zip Code:30263-1209
Practice Address - Country:US
Practice Address - Phone:678-423-4610
Practice Address - Fax:770-254-7419
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PATHWAYS CENTER FOR BEHAVIORAL AND DEVELOPMENTAL GROWTH
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-12-15
Last Update Date:2016-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000599332NMedicaid
GA=========OtherTAX ID NUMBER
GA000599332NMedicaid