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General NPI Number Information
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NPI Number | 1225271422
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Entity Type | Individual
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Provider Name | MOHAMMAD MEHDI MOMTAHAN PH.D.
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Gender | Male
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Dates
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Enumeration Date | 04/17/2009
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Last Update Date | 01/05/2015
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Provider Practice Location Address
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Address Line | 59 HILLSIDE TRACE SUITE 113
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City | DALLAS
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State | GA
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Zip | 30157-3315
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Country | US
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Telephone | 770-443-1644
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Fax | 770-443-1633
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Provider Business Mailing Address
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Address Line | 59 HILLSIDE TRCE SUITE 113
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City | DALLAS
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State | GA
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Zip | 30157-9476
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Country | US
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Telephone | 770-443-1644
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Fax | 770-443-1633
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101Y00000X
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Taxonomy Name | Counselor
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License Number | NCC 210724
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License Number State | GA
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Taxonomy #2
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Taxonomy Code | 101YA0400X
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Taxonomy Name | Addiction (Substance Use Disorder) Counselor
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License Number | C0040
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License Number State | GA
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Taxonomy #3
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Taxonomy Code | 101YA0400X
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Taxonomy Name | Addiction (Substance Use Disorder) Counselor
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License Number | MAC 12619
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License Number State | IN
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Taxonomy #4
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Taxonomy Code | 101YA0400X
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Taxonomy Name | Addiction (Substance Use Disorder) Counselor
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License Number | ICAADC 202225
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License Number State | GA
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Taxonomy #5
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Taxonomy Code | 101YA0400X
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Taxonomy Name | Addiction (Substance Use Disorder) Counselor
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License Number | CCODP-D 0004
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License Number State | GA
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Taxonomy #6
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Taxonomy Code | 101YM0800X
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Taxonomy Name | Mental Health Counselor
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License Number | ACS 00557
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License Number State | GA
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Taxonomy #7
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Taxonomy Code | 101YP2500X
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Taxonomy Name | Professional Counselor
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License Number | LPC004345
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License Number State | GA
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Taxonomy #8
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Taxonomy Code | 174400000X
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Taxonomy Name | Specialist
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License Number | CFAS 12619
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License Number State | IN
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Taxonomy #9
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Taxonomy Code | 174400000X
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Taxonomy Name | Specialist
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License Number | BDFC 12619
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License Number State | IN
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