Provider Demographics
NPI:1699895425
Name:FULTON COUNTY GOVT MHDDAD
Entity type:Organization
Organization Name:FULTON COUNTY GOVT MHDDAD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:BARBARA
Authorized Official - Middle Name:JACKSON
Authorized Official - Last Name:LATTIMORE
Authorized Official - Suffix:
Authorized Official - Credentials:PH D
Authorized Official - Phone:404-730-0230
Mailing Address - Street 1:115 MARTIN LUTHER KING JR DR SW
Mailing Address - Street 2:SUITE 277
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30303-3536
Mailing Address - Country:US
Mailing Address - Phone:404-730-0230
Mailing Address - Fax:404-730-0341
Practice Address - Street 1:115 MARTIN LUTHER KING JR DR SW
Practice Address - Street 2:SUITE 277
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30303-3536
Practice Address - Country:US
Practice Address - Phone:404-730-0230
Practice Address - Fax:404-730-0341
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-29
Last Update Date:2008-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA=========OtherTAX ID NO
GAGRP394Medicare PIN