Healthcare Provider Details

I. General information

NPI: 1437299625
Provider Name (Legal Business Name): FULTON COUNTY MENTAL HEALTH CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/07/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

475 FAIRBURN RD SW
ATLANTA GA
30331-1907
US

IV. Provider business mailing address

475 FAIRBURN RD SW
ATLANTA GA
30331-1907
US

V. Phone/Fax

Practice location:
  • Phone: 404-691-9627
  • Fax: 404-691-9793
Mailing address:
  • Phone: 404-691-9627
  • Fax: 404-691-9793

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License NumberCSW003136
License Number StateGA

VIII. Authorized Official

Name: MR. ERNEST EGLEN III
Title or Position: THERAPIST
Credential: LCSW
Phone: 404-691-9627