Provider Demographics
NPI:1528103512
Name:DEKALB COMMUNITY SERVICE BOARD
Entity type:Organization
Organization Name:DEKALB COMMUNITY SERVICE BOARD
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:COO
Authorized Official - Prefix:
Authorized Official - First Name:FABIO
Authorized Official - Middle Name:BRUNO
Authorized Official - Last Name:VAN DER MERWE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:404-294-3836
Mailing Address - Street 1:445 WINN WAY FL 4
Mailing Address - Street 2:
Mailing Address - City:DECATUR
Mailing Address - State:GA
Mailing Address - Zip Code:30030-1707
Mailing Address - Country:US
Mailing Address - Phone:404-294-3836
Mailing Address - Fax:770-451-8018
Practice Address - Street 1:3807 CLAIRMONT ROAD NE
Practice Address - Street 2:
Practice Address - City:CHAMBLEE
Practice Address - State:GA
Practice Address - Zip Code:30341
Practice Address - Country:US
Practice Address - Phone:770-457-5867
Practice Address - Fax:770-451-8018
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:DEKALB COMMUNITY SERVICE BOARD
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-02-20
Last Update Date:2020-05-01
Deactivation Date:2020-04-24
Deactivation Code:
Reactivation Date:2020-05-01
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000599519GMedicaid