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General NPI Number Information
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NPI Number | 1780823062
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Entity Type | Organization
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Legal Business Name | SOUTH MENTAL HEALTH
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Dates
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Enumeration Date | 02/11/2009
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Last Update Date | 02/12/2009
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Provider Practice Location Address
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Address Line | 1636 CONNALLY DR
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City | EAST POINT
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State | GA
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Zip | 30344-2558
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Country | US
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Telephone | 404-762-4042
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Fax | 404-762-3626
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Provider Business Mailing Address
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Address Line | 115 MARTIN LUTHER KING JR DR SW STE 277
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City | ATLANTA
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State | GA
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Zip | 30303-3553
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Country | US
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Telephone | 404-730-0230
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Fax | 404-730-0341
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Authorized Official
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Title or Position | DIRECTOR
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Name | BARBARA J LATTIMORE
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Credential | PHD, LPC
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Telephone | 404-730-0249
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number | CSW003394
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License Number State | GA
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