Provider Demographics
NPI:1568569135
Name:MOORE MENTAL HEALTH SERVICES, CORPORATION
Entity Type:Organization
Organization Name:MOORE MENTAL HEALTH SERVICES, CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MS
Authorized Official - First Name:ERNA
Authorized Official - Middle Name:H
Authorized Official - Last Name:KLINKHAMMER-MOORE
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:404-377-4706
Mailing Address - Street 1:2394 CHARLESTON OAKS LN
Mailing Address - Street 2:
Mailing Address - City:DECATUR
Mailing Address - State:GA
Mailing Address - Zip Code:30030-1451
Mailing Address - Country:US
Mailing Address - Phone:404-377-4706
Mailing Address - Fax:404-377-4174
Practice Address - Street 1:2394 CHARLESTON OAKS LN
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:GA
Practice Address - Zip Code:30030-1451
Practice Address - Country:US
Practice Address - Phone:404-377-4706
Practice Address - Fax:404-377-4174
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-17
Last Update Date:2013-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACSW0020891041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA055003553AMedicaid
GA80BBDJHMedicare ID - Type Unspecified
GAS25019Medicare UPIN