Healthcare Provider Details

I. General information

NPI: 1043386436
Provider Name (Legal Business Name): FULTON COUNTY MHDDAD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/28/2006
Last Update Date: 01/07/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

186 SUNSET AVENUE, NW
ATLANTA GA
30314-4059
US

IV. Provider business mailing address

99 JESSE HILL JR DRIVE SUITE 402
ATLANTA GA
30303-3045
US

V. Phone/Fax

Practice location:
  • Phone: 404-612-9328
  • Fax:
Mailing address:
  • Phone: 404-730-1059
  • Fax: 404-730-1233

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State

VIII. Authorized Official

Name: MS. LINDA JEFFERSON
Title or Position: HEALTH PROGRAM ADMINISTRATOR
Credential:
Phone: 404-730-1059