Healthcare Provider Details

I. General information

NPI: 1376069294
Provider Name (Legal Business Name): MR. DAVE MOORTHY
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

Provider Other Name: MR. KAIRALY SADANAM DEKSHINAMOORTHY

II. Dates (important events)

Enumeration Date: 08/22/2017
Last Update Date: 12/30/2025
Certification Date: 12/30/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2055 SUGARLOAF CIR STE 575
DULUTH GA
30097-9804
US

IV. Provider business mailing address

6290 ABBOTTS BRIDGE RD STE 502
JOHNS CREEK GA
30097-5714
US

V. Phone/Fax

Practice location:
  • Phone: 404-999-7971
  • Fax:
Mailing address:
  • Phone: 678-936-4057
  • Fax: 770-623-8846

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberLPC008255
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberC0108
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: