Provider Demographics
NPI:1043837065
Name:EADY, MALCOLM JAQUAN
Entity Type:Individual
Prefix:
First Name:MALCOLM
Middle Name:JAQUAN
Last Name:EADY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:685 ROUNTREE RD APT D26
Mailing Address - Street 2:
Mailing Address - City:RIVERDALE
Mailing Address - State:GA
Mailing Address - Zip Code:30274-3457
Mailing Address - Country:US
Mailing Address - Phone:404-317-3055
Mailing Address - Fax:
Practice Address - Street 1:6849 PEACHTREE DUNWOODY RD BLDG A1
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30328-6769
Practice Address - Country:US
Practice Address - Phone:678-691-2206
Practice Address - Fax:404-393-3133
Is Sole Proprietor?:No
Enumeration Date:2020-06-26
Last Update Date:2020-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000000OtherRBT