Provider Demographics
NPI:1427204775
Name:CLAYTON MHDDAD
Entity Type:Organization
Organization Name:CLAYTON MHDDAD
Other - Org Name:CLAYTON CENTER CSB
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:JADE
Authorized Official - Middle Name:
Authorized Official - Last Name:BENEFIELD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:770-478-2280
Mailing Address - Street 1:112 BROAD ST
Mailing Address - Street 2:
Mailing Address - City:JONESBORO
Mailing Address - State:GA
Mailing Address - Zip Code:30236-3563
Mailing Address - Country:US
Mailing Address - Phone:770-478-2280
Mailing Address - Fax:770-477-9772
Practice Address - Street 1:6278 HOLIDAY BLVD
Practice Address - Street 2:
Practice Address - City:FOREST PARK
Practice Address - State:GA
Practice Address - Zip Code:30297-4262
Practice Address - Country:US
Practice Address - Phone:770-478-2280
Practice Address - Fax:770-477-9772
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-08-18
Last Update Date:2008-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251C00000XAgenciesDay Training, Developmentally Disabled Services
No251S00000XAgenciesCommunity/Behavioral Health
No261QD1600XAmbulatory Health Care FacilitiesClinic/CenterDevelopmental Disabilities
No261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
No261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000606922ANMedicaid
GA000606922ANMedicaid