Basic Information
| Provider Information | |||||||||
| NPI: | 1982813309 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | DEKALB COMMUNITY SERVICE BOARD | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | NORTH DEKALB MENTAL HEALTH CENTER | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 445 WINN WAY | ||||||||
| Address2: | |||||||||
| City: | DECATUR | ||||||||
| State: | GA | ||||||||
| PostalCode: | 300301707 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4045087796 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 3807 CLAIRMONT RD | ||||||||
| Address2: | |||||||||
| City: | CHAMBLEE | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303414911 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7704575867 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/22/2007 | ||||||||
| LastUpdateDate: | 04/21/2020 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | VAN DER MERWE | ||||||||
| AuthorizedOfficialFirstName: | FABIO | ||||||||
| AuthorizedOfficialMiddleName: | BRUNO | ||||||||
| AuthorizedOfficialTitleorPosition: | COO | ||||||||
| AuthorizedOfficialTelephone: | 4042943836 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 04/21/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM0801X | 000692 | GA | Y | Ambulatory Health Care Facilities | Clinic/Center | Mental Health (Including Community Mental Health Center) |
No ID Information.