MEDICARE: FULTON COUNTY GOVT MHDDAD

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	:	1699895425
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	FULTON COUNTY GOVT MHDDAD

Provider Business Mailing Address
First Line	:	115 MARTIN LUTHER KING JR DR SW
Second Line	:	SUITE 277
City	:	ATLANTA
State	:	GA
Zip	:	30303-3536
Country	:	US
Telephone Number	:	404-730-0230
Fax Number	:	404-730-0341

Provider Business Practice Location Address
First Line	:	115 MARTIN LUTHER KING JR DR SW
Second Line	:	SUITE 277
City	:	ATLANTA
State	:	GA
Zip	:	30303-3536
Country	:	US
Telephone Number	:	404-730-0230
Fax Number	:	404-730-0341

Authorized Official
Title or Position	:	DIRECTOR
Name	:	MRS. BARBARA JACKSON LATTIMORE
Credential	:	PH D
Telephone Number	:	404-730-0230

Provider Enumeration Date	:	03/29/2007
Last Update Date	:	04/20/2008

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