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NPI Code Detail

MEDICARE: MATLOCK RESOURCE CENTER, LLC

MEDICARE: MATLOCK RESOURCE CENTER, LLC
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
1261QM0850XAdult Mental Health Clinic/Center

General Provider Information

NPI Number : 1639684533
Entity Type Code : Organization
Provider Name (Legal Business Name) : MATLOCK RESOURCE CENTER, LLC
Provider Business Mailing Address
First Line : PO BOX 711
Second Line :
City : DULUTH
State : GA
Zip : 30096-0013
Country : US
Telephone Number :
Fax Number :
Provider Business Practice Location Address
First Line : 2180 SATELLITE BLVD STE 400
Second Line :
City : DULUTH
State : GA
Zip : 30097-4927
Country : US
Telephone Number : 770-464-5831
Fax Number :
Authorized Official
Title or Position : CEO/LEAD THERAPIST
Name : MISS TAMELA MCDONALD
Credential : LPC, NCC, CCMHC
Telephone Number : 770-464-5831
Provider Enumeration Date : 12/13/2017
Last Update Date : 06/11/2019

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Directions to “MATLOCK RESOURCE CENTER, LLC ” Practice Location

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