Provider Demographics
NPI:1235646217
Name:CLAYTON CENTER MHADDD
Entity Type:Organization
Organization Name:CLAYTON CENTER MHADDD
Other - Org Name:CLAYTON CENTER CSB
Other - Org Type:Doing Business As
Authorized Official - Title/Position:COO
Authorized Official - Prefix:
Authorized Official - First Name:TIFFANY
Authorized Official - Middle Name:
Authorized Official - Last Name:TOM-JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:770-478-2280
Mailing Address - Street 1:157 SMITH ST
Mailing Address - Street 2:
Mailing Address - City:JONESBORO
Mailing Address - State:GA
Mailing Address - Zip Code:30236-3546
Mailing Address - Country:US
Mailing Address - Phone:770-473-2649
Mailing Address - Fax:
Practice Address - Street 1:5930 HIGHWAY 85 UNIT 401
Practice Address - Street 2:
Practice Address - City:RIVERDALE
Practice Address - State:GA
Practice Address - Zip Code:30274-1502
Practice Address - Country:US
Practice Address - Phone:770-997-8137
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CLAYTON CENTER MHADDD
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2017-12-29
Last Update Date:2017-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental Illness