Provider Demographics
NPI:1780823062
Name:SOUTH MENTAL HEALTH
Entity Type:Organization
Organization Name:SOUTH MENTAL HEALTH
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:BARBARA
Authorized Official - Middle Name:J
Authorized Official - Last Name:LATTIMORE
Authorized Official - Suffix:
Authorized Official - Credentials:PHD, LPC
Authorized Official - Phone:404-730-0249
Mailing Address - Street 1:115 MARTIN LUTHER KING JR DR SW STE 277
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30303-3553
Mailing Address - Country:US
Mailing Address - Phone:404-730-0230
Mailing Address - Fax:404-730-0341
Practice Address - Street 1:1636 CONNALLY DR
Practice Address - Street 2:
Practice Address - City:EAST POINT
Practice Address - State:GA
Practice Address - Zip Code:30344-2558
Practice Address - Country:US
Practice Address - Phone:404-762-4042
Practice Address - Fax:404-762-3626
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-02-11
Last Update Date:2009-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACSW0033941041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAGRP394Medicare PIN