Healthcare Provider Details

I. General information

NPI: 1528103512
Provider Name (Legal Business Name): DEKALB COMMUNITY SERVICE BOARD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/20/2007
Last Update Date: 05/01/2020
Certification Date: 05/01/2020
Deactivation Date: 04/24/2020
Reactivation Date: 05/01/2020

III. Provider practice location address

3807 CLAIRMONT ROAD NE
CHAMBLEE GA
30341
US

IV. Provider business mailing address

445 WINN WAY FL 4
DECATUR GA
30030-1707
US

V. Phone/Fax

Practice location:
  • Phone: 770-457-5867
  • Fax: 770-451-8018
Mailing address:
  • Phone: 404-294-3836
  • Fax: 770-451-8018

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: FABIO BRUNO VAN DER MERWE
Title or Position: COO
Credential:
Phone: 404-294-3836