Provider Demographics
NPI:1609024157
Name:CLAYTON COMMUNITY MENTAL HEALTH SUBSTANCE AB
Entity Type:Organization
Organization Name:CLAYTON COMMUNITY MENTAL HEALTH SUBSTANCE AB
Other - Org Name:CLAYTON CSB
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:MARKETEIA
Authorized Official - Middle Name:
Authorized Official - Last Name:GANT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:770-605-1126
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:770-478-8722
Practice Address - Street 1:853 BATTLECREEK RD
Practice Address - Street 2:
Practice Address - City:JONESBORO
Practice Address - State:GA
Practice Address - Zip Code:30236-1919
Practice Address - Country:US
Practice Address - Phone:770-478-1099
Practice Address - Fax:770-478-8722
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CLAYTON COMMUNITY MENTAL HEALTH SUBSTANCE ABUSE DEVE SVCS BOARD
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-09-08
Last Update Date:2011-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
261QM0801X
GA261QM0850X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
No261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00604205EMedicaid
GAGRP2322OtherMEDICARE
GAGRP2322Medicare PIN