Provider Demographics
NPI:1063420875
Name:PRIGATANO, MARK J (PHD)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:J
Last Name:PRIGATANO
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:146 PIERCE AVE
Mailing Address - Street 2:
Mailing Address - City:MACON
Mailing Address - State:GA
Mailing Address - Zip Code:31204-2871
Mailing Address - Country:US
Mailing Address - Phone:478-746-2333
Mailing Address - Fax:478-845-4493
Practice Address - Street 1:146 PIERCE AVE
Practice Address - Street 2:
Practice Address - City:MACON
Practice Address - State:GA
Practice Address - Zip Code:31204-2871
Practice Address - Country:US
Practice Address - Phone:478-746-2333
Practice Address - Fax:478-845-4493
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-04
Last Update Date:2014-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPSY001999103TC0700X, 103TC2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty
No103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & AdolescentGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000730254CMedicaid