Provider Demographics
| NPI: | 1922296813 |
|---|---|
| Name: | CLAYTON MHDDAD |
| Entity Type: | Organization |
| Organization Name: | CLAYTON MHDDAD |
| Other - Org Name: | CLAYTON CSB |
| Other - Org Type: | Doing Business As |
| Authorized Official - Title/Position: | EXECUTIVE DIRECTOR |
| Authorized Official - Prefix: | MR |
| Authorized Official - First Name: | TERRY |
| Authorized Official - Middle Name: | |
| Authorized Official - Last Name: | COLE |
| Authorized Official - Suffix: | |
| Authorized Official - Credentials: | |
| Authorized Official - Phone: | 770-478-2280 |
| Mailing Address - Street 1: | 157 SMITH ST |
| Mailing Address - Street 2: | |
| Mailing Address - City: | JONESBORO |
| Mailing Address - State: | GA |
| Mailing Address - Zip Code: | 30236-3546 |
| Mailing Address - Country: | US |
| Mailing Address - Phone: | 770-478-2280 |
| Mailing Address - Fax: | 770-477-9772 |
| Practice Address - Street 1: | 217 STOCKBRIDGE RD |
| Practice Address - Street 2: | |
| Practice Address - City: | JONESBORO |
| Practice Address - State: | GA |
| Practice Address - Zip Code: | 30236-3628 |
| Practice Address - Country: | US |
| Practice Address - Phone: | 770-471-4617 |
| Practice Address - Fax: | 770-471-7817 |
| EIN: | <UNAVAIL> |
| Is Organization Subpart?: | Yes |
| Parent Organization LBN: | CLAYTON MHDDAD |
| Parent Organization TIN: | <UNAVAIL> |
| Enumeration Date: | 2007-10-05 |
| Last Update Date: | 2011-11-15 |
| Deactivation Date: | |
| Deactivation Code: | |
| Reactivation Date: |
Provider Taxonomies
| Primary? | Code | Type | Classification | Specialization | Group |
|---|---|---|---|---|---|
| Yes | 251S00000X | Agencies | Community/Behavioral Health | Group - Multi-Specialty | |
| No | 101Y00000X | Behavioral Health & Social Service Providers | Counselor | Group - Multi-Specialty | |
| No | 101YA0400X | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | Group - Multi-Specialty |
| No | 101YM0800X | Behavioral Health & Social Service Providers | Counselor | Mental Health | Group - Multi-Specialty |
| No | 103TA0700X | Behavioral Health & Social Service Providers | Psychologist | Adult Development & Aging | Group - Multi-Specialty |
| No | 103TM1800X | Behavioral Health & Social Service Providers | Psychologist | Intellectual & Developmental Disabilities | Group - Multi-Specialty |
| No | 251C00000X | Agencies | Day Training, Developmentally Disabled Services | ||
| No | 261Q00000X | Ambulatory Health Care Facilities | Clinic/Center | Group - Multi-Specialty | |
| No | 261QA0600X | Ambulatory Health Care Facilities | Clinic/Center | Adult Day Care | Group - Multi-Specialty |
| No | 261QD1600X | Ambulatory Health Care Facilities | Clinic/Center | Developmental Disabilities | Group - Multi-Specialty |
| No | 261QM0801X | Ambulatory Health Care Facilities | Clinic/Center | Mental Health (Including Community Mental Health Center) | Group - Multi-Specialty |
| No | 261QM0850X | Ambulatory Health Care Facilities | Clinic/Center | Adult Mental Health |
Provider Identifiers
| State | Identifier ID | ID Type | Issuer |
|---|---|---|---|
| GA | 00395458A | Medicaid | |
| GA | 00604205G | Medicaid | |
| GA | GRP2322 | Medicare PIN |
