Healthcare Provider Details

I. General information

NPI: 1982813309
Provider Name (Legal Business Name): DEKALB COMMUNITY SERVICE BOARD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/22/2007
Last Update Date: 04/21/2020
Certification Date: 04/21/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3807 CLAIRMONT RD
CHAMBLEE GA
30341-4911
US

IV. Provider business mailing address

445 WINN WAY
DECATUR GA
30030-1707
US

V. Phone/Fax

Practice location:
  • Phone: 770-457-5867
  • Fax:
Mailing address:
  • Phone: 404-508-7796
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number000692
License Number StateGA

VIII. Authorized Official

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