{
"Npi": {
"NPI": "1376069294",
"EntityType": "Individual",
"ReplacementNPI": null,
"EIN": null,
"IsSoleProprietor": "Y",
"IsOrgSubpart": null,
"ParentOrgLBN": null,
"ParentOrgTIN": null,
"OrgName": null,
"LastName": "MOORTHY",
"FirstName": "DAVE",
"MiddleName": null,
"NamePrefix": "MR.",
"NameSuffix": null,
"Credential": null,
"OtherOrgName": null,
"OtherOrgNameTypeCode": null,
"OtherLastName": "DEKSHINAMOORTHY",
"OtherFirstName": "KAIRALY",
"OtherMiddleName": "SADANAM",
"OtherNamePrefix": "MR.",
"OtherNameSuffix": null,
"OtherCredential": null,
"OtherLastNameTypeCode": "1",
"FirstLineMailingAddress": "6290 ABBOTTS BRIDGE RD STE 502",
"SecondLineMailingAddress": null,
"MailingAddressCityName": "JOHNS CREEK",
"MailingAddressStateName": "GA",
"MailingAddressPostalCode": "30097-5714",
"MailingAddressCountryCode": "US",
"MailingAddressTelephoneNumber": "678-936-4057",
"MailingAddressFaxNumber": "770-623-8846",
"FirstLinePracticeLocationAddress": "2055 SUGARLOAF CIR STE 575",
"SecondLinePracticeLocationAddress": null,
"PracticeLocationAddressCityName": "DULUTH",
"PracticeLocationAddressStateName": "GA",
"PracticeLocationAddressPostalCode": "30097-9804",
"PracticeLocationAddressCountryCode": "US",
"PracticeLocationAddressTelephoneNumber": "404-999-7971",
"PracticeLocationAddressFaxNumber": null,
"EnumerationDate": "08/22/2017",
"LastUpdateDate": "12/30/2025",
"NPIDeactivationReasonCode": null,
"NPIDeactivationReason": null,
"NPIDeactivationDate": null,
"NPIReactivationDate": null,
"GenderCode": "M",
"Gender": "Male",
"AuthorizedOfficialLastName": null,
"AuthorizedOfficialFirstName": null,
"AuthorizedOfficialMiddleName": null,
"AuthorizedOfficialTitle": null,
"AuthorizedOfficialNamePrefix": null,
"AuthorizedOfficialNameSuffix": null,
"AuthorizedOfficialCredential": null,
"AuthorizedOfficialTelephoneNumber": null,
"Taxonomies": {
"Taxonomy": [
{
"TaxonomyCode": "101YP2500X",
"TaxonomyName": "Professional Counselor",
"LicenseNumber": "LPC008255",
"LicenseNumberStateCode": "GA",
"PrimaryTaxonomySwitch": "Y"
},
{
"TaxonomyCode": "101YA0400X",
"TaxonomyName": "Addiction (Substance Use Disorder) Counselor",
"LicenseNumber": "C0108",
"LicenseNumberStateCode": "GA",
"PrimaryTaxonomySwitch": "N"
}
]
},
"HealthcareProviderTaxonomyGroups": {
"HealthcareProviderTaxonomyGroup": {
"HealthcareProviderTaxonomyGroupName": "193200000X MULTI-SPECIALTY GROUP",
"HealthcareProviderTaxonomyGroupDescription": "Multi-Specialty Group - A business group of one or more individual practitioners, who practice with different areas of specialization."
}
}
}
}