Healthcare Provider Details

I. General information

NPI: 1780591438
Provider Name (Legal Business Name): DEROAD TECHNOLOGY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/27/2026
Last Update Date: 08/27/2026
Certification Date: 08/27/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1373 EUCLID AVE NE
ATLANTA GA
30307-1581
US

IV. Provider business mailing address

1405 SIMONE DR
CONYERS GA
30094-1107
US

V. Phone/Fax

Practice location:
  • Phone: 404-690-1066
  • Fax:
Mailing address:
  • Phone: 404-690-1066
  • Fax:

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: JOSEPH D ALI
Title or Position: CEO
Credential:
Phone: 404-690-1066