Provider Demographics
NPI:1427738731
Name:AVENUE PARC
Entity type:Organization
Organization Name:AVENUE PARC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:KYJUANA
Authorized Official - Middle Name:
Authorized Official - Last Name:MOSES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:225-287-4146
Mailing Address - Street 1:950 EAGLES LANDING PKWY STE 237
Mailing Address - Street 2:
Mailing Address - City:STOCKBRIDGE
Mailing Address - State:GA
Mailing Address - Zip Code:30281-7343
Mailing Address - Country:US
Mailing Address - Phone:225-287-4146
Mailing Address - Fax:
Practice Address - Street 1:646 N FOSTER DR STE B
Practice Address - Street 2:
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70806-1887
Practice Address - Country:US
Practice Address - Phone:225-287-4146
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-07-20
Last Update Date:2024-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounselingGroup - Multi-Specialty
No261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
No261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health