Healthcare Provider Details

I. General information

NPI: 1245101724
Provider Name (Legal Business Name): THATO MTHENJANE
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/16/2025
Last Update Date: 09/16/2025
Certification Date: 09/16/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

50 LENOX POINTE NE STE A
ATLANTA GA
30324-3103
US

IV. Provider business mailing address

870 MORELAND AVE SE
ATLANTA GA
30316-2663
US

V. Phone/Fax

Practice location:
  • Phone: 678-824-6590
  • Fax:
Mailing address:
  • Phone: 470-433-1751
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License Number
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: