Healthcare Provider Details

I. General information

NPI: 1275988354
Provider Name (Legal Business Name): CLIFFORD ALLEN GAVIN JR. LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/26/2016
Last Update Date: 08/07/2020
Certification Date: 08/07/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

445 WINN WAY
DECATUR GA
30030-1707
US

IV. Provider business mailing address

270 CARPENTER DR STE 400
SANDY SPRINGS GA
30328-4933
US

V. Phone/Fax

Practice location:
  • Phone: 140-450-8770
  • Fax:
Mailing address:
  • Phone: 678-460-0345
  • Fax: 678-460-0350

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberCSW006943
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: