Provider Demographics
NPI:1649536640
Name:PRIMARY PATHWAYS, LLC
Entity type:Organization
Organization Name:PRIMARY PATHWAYS, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:AGENT
Authorized Official - Prefix:
Authorized Official - First Name:JACQUELINE
Authorized Official - Middle Name:D
Authorized Official - Last Name:MURRY
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:770-500-5508
Mailing Address - Street 1:3904 N DRUID HILLS RD # 214
Mailing Address - Street 2:
Mailing Address - City:DECATUR
Mailing Address - State:GA
Mailing Address - Zip Code:30033-3105
Mailing Address - Country:US
Mailing Address - Phone:770-500-5508
Mailing Address - Fax:404-597-4050
Practice Address - Street 1:1258 CONCORD RD SE STE 104
Practice Address - Street 2:
Practice Address - City:SMYRNA
Practice Address - State:GA
Practice Address - Zip Code:30080-4302
Practice Address - Country:US
Practice Address - Phone:770-500-5508
Practice Address - Fax:404-597-4050
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-04-04
Last Update Date:2020-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GASLP005791235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA674689092DMedicaid