Basic Information
Provider Information | |||||||||
NPI: | 1528103512 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | DEKALB COMMUNITY SERVICE BOARD | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | NORTH DEKALB MENTAL HEALTH CENTER | ||||||||
OtherOrganizationType: | 5 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 445 WINN WAY FL 4 | ||||||||
Address2: |   | ||||||||
City: | DECATUR | ||||||||
State: | GA | ||||||||
PostalCode: | 300301707 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4042943836 | ||||||||
FaxNumber: | 7704518018 | ||||||||
Practice Location | |||||||||
Address1: | 3807 CLAIRMONT ROAD NE | ||||||||
Address2: |   | ||||||||
City: | CHAMBLEE | ||||||||
State: | GA | ||||||||
PostalCode: | 30341 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7704575867 | ||||||||
FaxNumber: | 7704518018 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 02/20/2007 | ||||||||
LastUpdateDate: | 05/01/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: | 04/24/2020 | ||||||||
NPIReactivationDate: | 05/01/2020 | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | VAN DER MERWE | ||||||||
AuthorizedOfficialFirstName: | FABIO | ||||||||
AuthorizedOfficialMiddleName: | BRUNO | ||||||||
AuthorizedOfficialTitleorPosition: | COO | ||||||||
AuthorizedOfficialTelephone: | 4042943836 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | DEKALB COMMUNITY SERVICE BOARD | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 05/01/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X |   |   | Y |   | Agencies | Community/Behavioral Health |   |
No ID Information.