Provider Demographics
NPI:1225271422
Name:MOMTAHAN, MOHAMMAD MEHDI (PHD)
Entity Type:Individual
Prefix:DR
First Name:MOHAMMAD
Middle Name:MEHDI
Last Name:MOMTAHAN
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:59 HILLSIDE TRCE
Mailing Address - Street 2:SUITE 113
Mailing Address - City:DALLAS
Mailing Address - State:GA
Mailing Address - Zip Code:30157-9476
Mailing Address - Country:US
Mailing Address - Phone:770-443-1644
Mailing Address - Fax:770-443-1633
Practice Address - Street 1:59 HILLSIDE TRACE
Practice Address - Street 2:SUITE 113
Practice Address - City:DALLAS
Practice Address - State:GA
Practice Address - Zip Code:30157-3315
Practice Address - Country:US
Practice Address - Phone:770-443-1644
Practice Address - Fax:770-443-1633
Is Sole Proprietor?:No
Enumeration Date:2009-04-17
Last Update Date:2015-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GANCC 210724101Y00000X
GAC0040101YA0400X
INMAC 12619101YA0400X
GAICAADC 202225101YA0400X
GACCODP-D 0004101YA0400X
GAACS 00557101YM0800X
GALPC004345101YP2500X
INCFAS 12619174400000X
INBDFC 12619174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No174400000XOther Service ProvidersSpecialist