=====================================================
General NPI Number Information
=====================================================
NPI Number | 1881405850
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MALABAR COUNSELING GROUP LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/17/2025
-----------------------------------------------------
Last Update Date | 01/17/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1296 MCLENDON AVE NE
-----------------------------------------------------
City | ATLANTA
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30307-2088
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 770-490-2164
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1296 MCLENDON AVE NE
-----------------------------------------------------
City | ATLANTA
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30307-2088
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 770-490-2164
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | MR. JACOB JACOB
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 770-490-2164
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103TC0700X
-----------------------------------------------------
Taxonomy Name | Clinical Psychologist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------