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General NPI Number Information
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NPI Number | 1639684533
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Entity Type | Organization
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Legal Business Name | MATLOCK RESOURCE CENTER, LLC
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Dates
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Enumeration Date | 12/13/2017
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Last Update Date | 06/11/2019
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Provider Practice Location Address
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Address Line | 2180 SATELLITE BLVD STE 400
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City | DULUTH
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State | GA
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Zip | 30097-4927
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Country | US
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Telephone | 770-464-5831
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 711
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City | DULUTH
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State | GA
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Zip | 30096-0013
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | CEO/LEAD THERAPIST
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Name | MISS TAMELA MCDONALD
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Credential | LPC, NCC, CCMHC
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Telephone | 770-464-5831
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QM0850X
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Taxonomy Name | Adult Mental Health Clinic/Center
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License Number |
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License Number State |
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