Provider Demographics
NPI:1528316163
Name:PEMBERTON, EVERSLEY DEVON (PHD)
Entity type:Individual
Prefix:DR
First Name:EVERSLEY
Middle Name:DEVON
Last Name:PEMBERTON
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 1:1477 RIVERROCK TRL
Mailing Address - Street 2:
Mailing Address - City:RIVERDALE
Mailing Address - State:GA
Mailing Address - Zip Code:30296-1169
Mailing Address - Country:US
Mailing Address - Phone:404-808-8207
Mailing Address - Fax:678-519-5762
Practice Address - Street 1:340 BOULEVARD NE
Practice Address - Street 2:345
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30312-1273
Practice Address - Country:US
Practice Address - Phone:404-653-0322
Practice Address - Fax:404-653-0466
Is Sole Proprietor?:No
Enumeration Date:2012-08-28
Last Update Date:2013-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPSY003607103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003127613AMedicaid