Provider Demographics
NPI:1992984264
Name:CLAYTON MHDDAD
Entity type:Organization
Organization Name:CLAYTON MHDDAD
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:JADE
Authorized Official - Middle Name:
Authorized Official - Last Name:BENEFIELD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:770-478-2280
Mailing Address - Street 1:112 BROAD ST
Mailing Address - Street 2:
Mailing Address - City:JONESBORO
Mailing Address - State:GA
Mailing Address - Zip Code:30236-3563
Mailing Address - Country:US
Mailing Address - Phone:770-478-2280
Mailing Address - Fax:770-477-9772
Practice Address - Street 1:217 STOCKBRIDGE RD
Practice Address - Street 2:
Practice Address - City:JONESBORO
Practice Address - State:GA
Practice Address - Zip Code:30236-3628
Practice Address - Country:US
Practice Address - Phone:770-471-4617
Practice Address - Fax:770-471-7817
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CLAYTON MHDDAD
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-11-02
Last Update Date:2008-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
No251S00000XAgenciesCommunity/Behavioral HealthGroup - Multi-Specialty
No251C00000XAgenciesDay Training, Developmentally Disabled ServicesGroup - Multi-Specialty
No261QA0600XAmbulatory Health Care FacilitiesClinic/CenterAdult Day CareGroup - Multi-Specialty
No261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
No261Q00000XAmbulatory Health Care FacilitiesClinic/Center
No261QC1500XAmbulatory Health Care FacilitiesClinic/CenterCommunity Health
No261QD1600XAmbulatory Health Care FacilitiesClinic/CenterDevelopmental Disabilities
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
No103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Multi-Specialty
No104100000XBehavioral Health & Social Service ProvidersSocial WorkerGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00607076DMedicaid
GA00607076DMedicaid
GA26BDJGQMedicare PIN