Healthcare Provider Details

I. General information

NPI: 1760546543
Provider Name (Legal Business Name): PATHWAYS CENTER FOR BEHAVIORAL AND DEVELOPMENTAL GROWTH
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/19/2006
Last Update Date: 05/04/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

153 INDEPENDENCE DRIVE
CARROLLTON GA
30116-9000
US

IV. Provider business mailing address

122 GORDON COMMERCIAL DRIVE SUITE C
LAGRANGE GA
30240-5740
US

V. Phone/Fax

Practice location:
  • Phone: 770-836-6678
  • Fax: 770-830-2266
Mailing address:
  • Phone: 706-845-4045
  • Fax: 706-845-4367

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier000599332L
Identifier TypeMEDICAID
Identifier StateGA
Identifier Issuer

VIII. Authorized Official

Name: JADE RUSSELL BENEFIELD
Title or Position: EXECUTIVE DIRECTOR
Credential: MBA
Phone: 706-845-4045