Healthcare Provider Details

I. General information

NPI: 1043845373
Provider Name (Legal Business Name): IVY COLLABORATIVE HEALTHCARE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/06/2020
Last Update Date: 05/07/2024
Certification Date: 05/07/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2100 CENTRAL AVENUE STES 6 & 7
AUGUSTA GA
30904-6717
US

IV. Provider business mailing address

2100 CENTRAL AVENUE STES 6 & 7
AUGUSTA GA
30904-6709
US

V. Phone/Fax

Practice location:
  • Phone: 706-364-3461
  • Fax: 706-364-3481
Mailing address:
  • Phone: 706-364-3461
  • Fax: 706-364-3481

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License Number
License Number State

VIII. Authorized Official

Name: JOCELYN KELLY BAYLISS
Title or Position: AUTHORIZED OFFICIAL
Credential: MD
Phone: 706-364-3461