Provider Demographics
NPI:1447395488
Name:DEKALB COMMUNITY SERVICE BOARD
Entity Type:Organization
Organization Name:DEKALB COMMUNITY SERVICE BOARD
Other - Org Name:EAST DEKALB
Other - Org Type:Other Name
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:FABIO
Authorized Official - Middle Name:BRUNO
Authorized Official - Last Name:VAN DER MERWE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:404-294-3836
Mailing Address - Street 1:445 WINN WAY FL 4
Mailing Address - Street 2:
Mailing Address - City:DECATUR
Mailing Address - State:GA
Mailing Address - Zip Code:30030-1707
Mailing Address - Country:US
Mailing Address - Phone:404-294-3836
Mailing Address - Fax:
Practice Address - Street 1:2277 STONE MOUNTAIN LITHONIA RD
Practice Address - Street 2:
Practice Address - City:LITHONIA
Practice Address - State:GA
Practice Address - Zip Code:30058-5252
Practice Address - Country:US
Practice Address - Phone:770-270-2710
Practice Address - Fax:770-270-2714
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:DEKALB COMMUNITY SERVICE BOARD
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-02-20
Last Update Date:2023-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000603446PMedicaid