Provider Demographics
NPI:1043386436
Name:FULTON COUNTY MHDDAD
Entity Type:Organization
Organization Name:FULTON COUNTY MHDDAD
Other - Org Name:NEIGHBORHOOD UNION MENTAL HEALTH CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:HEALTH PROGRAM ADMINISTRATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:LINDA
Authorized Official - Middle Name:
Authorized Official - Last Name:JEFFERSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:404-730-1059
Mailing Address - Street 1:99 JESSE HILL JR DRIVE
Mailing Address - Street 2:SUITE 402
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30303-3045
Mailing Address - Country:US
Mailing Address - Phone:404-730-1059
Mailing Address - Fax:404-730-1233
Practice Address - Street 1:186 SUNSET AVENUE, NW
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30314-4059
Practice Address - Country:US
Practice Address - Phone:404-612-9328
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-28
Last Update Date:2011-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000066833AMedicaid