Provider Demographics
NPI:1376069294
Name:MOORTHY, DAVE
Entity Type:Individual
Prefix:MR
First Name:DAVE
Middle Name:
Last Name:MOORTHY
Suffix:
Gender:M
Credentials:
Other - Prefix:MR
Other - First Name:KAIRALY
Other - Middle Name:SADANAM
Other - Last Name:DEKSHINAMOORTHY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:6290 ABBOTTS BRIDGE RD STE 502
Mailing Address - Street 2:
Mailing Address - City:DULUTH
Mailing Address - State:GA
Mailing Address - Zip Code:30097-5714
Mailing Address - Country:US
Mailing Address - Phone:678-936-4057
Mailing Address - Fax:770-623-8846
Practice Address - Street 1:6290 ABBOTTS BRIDGE RD STE 502
Practice Address - Street 2:
Practice Address - City:DULUTH
Practice Address - State:GA
Practice Address - Zip Code:30097-5714
Practice Address - Country:US
Practice Address - Phone:678-936-4057
Practice Address - Fax:770-623-8846
Is Sole Proprietor?:Yes
Enumeration Date:2017-08-22
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAC0108101YA0400X
GALPC008255101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Multi-Specialty