Healthcare Provider Details

I. General information

NPI: 1043837065
Provider Name (Legal Business Name): MALCOLM JAQUAN EADY
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/26/2020
Last Update Date: 06/26/2020
Certification Date: 06/26/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6849 PEACHTREE DUNWOODY RD BLDG A1
ATLANTA GA
30328-6769
US

IV. Provider business mailing address

685 ROUNTREE RD APT D26
RIVERDALE GA
30274-3457
US

V. Phone/Fax

Practice location:
  • Phone: 678-691-2206
  • Fax: 404-393-3133
Mailing address:
  • Phone: 404-317-3055
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: