MEDICARE: DEKALB COMMUNITY SERVICE BOARD

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	251S00000X	Community/Behavioral Health Agency

General Provider Information

NPI Number	:	1497890214
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DEKALB COMMUNITY SERVICE BOARD

Provider Business Mailing Address
First Line	:	445 WINN WAY FL 4
Second Line	:
City	:	DECATUR
State	:	GA
Zip	:	30030-1707
Country	:	US
Telephone Number	:	404-294-3836
Fax Number	:

Provider Business Practice Location Address
First Line	:	4200 WATERLOO CIR
Second Line	:
City	:	TUCKER
State	:	GA
Zip	:	30084-2237
Country	:	US
Telephone Number	:	770-270-0160
Fax Number	:	770-270-0160

Authorized Official
Title or Position	:	COO
Name	:	FABIO BRUNO VAN DER MERWE
Credential	:
Telephone Number	:	404-294-3836

Provider Enumeration Date	:	02/20/2007
Last Update Date	:	04/24/2020

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