Provider Demographics
NPI:1447308911
Name:GEORGIA DEVELOPMENTAL CENTER
Entity type:Organization
Organization Name:GEORGIA DEVELOPMENTAL CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PSYCHOLOGIST
Authorized Official - Prefix:DR
Authorized Official - First Name:LILLEE
Authorized Official - Middle Name:
Authorized Official - Last Name:CLARK
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:770-538-4800
Mailing Address - Street 1:615 GREEN ST NW
Mailing Address - Street 2:SUITE 201
Mailing Address - City:GAINESVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30501-3378
Mailing Address - Country:US
Mailing Address - Phone:770-538-4800
Mailing Address - Fax:770-503-9299
Practice Address - Street 1:615 GREEN ST NW
Practice Address - Street 2:SUITE 201
Practice Address - City:GAINESVILLE
Practice Address - State:GA
Practice Address - Zip Code:30501-3378
Practice Address - Country:US
Practice Address - Phone:770-538-4800
Practice Address - Fax:770-503-9299
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-08
Last Update Date:2007-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPSY001290103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00566354AMedicaid
GA68BBDKNMedicare ID - Type Unspecified
GA00566354AMedicaid