Provider Demographics
NPI:1720441454
Name:PAVILION PSYCHOLOGICAL SERVICES LLC
Entity type:Organization
Organization Name:PAVILION PSYCHOLOGICAL SERVICES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ASHLEY
Authorized Official - Middle Name:
Authorized Official - Last Name:BAKER
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD
Authorized Official - Phone:770-668-4248
Mailing Address - Street 1:PO BOX 4551
Mailing Address - Street 2:
Mailing Address - City:SUWANEE
Mailing Address - State:GA
Mailing Address - Zip Code:30024-9004
Mailing Address - Country:US
Mailing Address - Phone:770-668-4248
Mailing Address - Fax:
Practice Address - Street 1:1445 HAW CREEK CORNERS CIRCLE EAST
Practice Address - Street 2:SUITE 501
Practice Address - City:CUMMING
Practice Address - State:GA
Practice Address - Zip Code:30041
Practice Address - Country:US
Practice Address - Phone:770-668-4248
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-03-31
Last Update Date:2016-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPSY003511103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Single Specialty