MEDICARE: DR. MOHAMMAD MEHDI MOMTAHAN PH.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101Y00000X	Counselor	NCC 210724	GA
2	101YA0400X	Addiction (Substance Use Disorder) Counselor	C0040	GA
3	101YA0400X	Addiction (Substance Use Disorder) Counselor	MAC 12619	IN
4	101YA0400X	Addiction (Substance Use Disorder) Counselor	ICAADC 202225	GA
5	101YA0400X	Addiction (Substance Use Disorder) Counselor	CCODP-D 0004	GA
6	101YM0800X	Mental Health Counselor	ACS 00557	GA
7	101YP2500X	Professional Counselor	LPC004345	GA
8	174400000X	Specialist	CFAS 12619	IN
9	174400000X	Specialist	BDFC 12619	IN

General Provider Information

NPI Number	:	1225271422
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MOHAMMAD MEHDI MOMTAHAN PH.D.

Provider Business Mailing Address
First Line	:	59 HILLSIDE TRCE
Second Line	:	SUITE 113
City	:	DALLAS
State	:	GA
Zip	:	30157-9476
Country	:	US
Telephone Number	:	770-443-1644
Fax Number	:	770-443-1633

Provider Business Practice Location Address
First Line	:	59 HILLSIDE TRACE
Second Line	:	SUITE 113
City	:	DALLAS
State	:	GA
Zip	:	30157-3315
Country	:	US
Telephone Number	:	770-443-1644
Fax Number	:	770-443-1633

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/17/2009
Last Update Date	:	01/05/2015

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