Provider Demographics
NPI:1720748262
Name:ASCENSION PSYCHIATRIC SERVICES LLC
Entity Type:Organization
Organization Name:ASCENSION PSYCHIATRIC SERVICES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:ANTHONY
Authorized Official - Middle Name:HAMES
Authorized Official - Last Name:HALL
Authorized Official - Suffix:
Authorized Official - Credentials:APRN
Authorized Official - Phone:310-890-6033
Mailing Address - Street 1:330 PHILLIPS DR
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30214-4375
Mailing Address - Country:US
Mailing Address - Phone:310-809-6033
Mailing Address - Fax:
Practice Address - Street 1:330 PHILLIPS DR
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30214-4375
Practice Address - Country:US
Practice Address - Phone:310-809-6033
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-12-25
Last Update Date:2021-12-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA1558904169Medicaid