Provider Demographics
NPI:1881956183
Name:CLAYTON COMMUNITY SERVICE BOARD
Entity type:Organization
Organization Name:CLAYTON COMMUNITY SERVICE BOARD
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:SUBSTANCE ABUSE COUNSELOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:DOROTHY
Authorized Official - Middle Name:A
Authorized Official - Last Name:FORTUCHANG
Authorized Official - Suffix:
Authorized Official - Credentials:MS, LAPC, NCC
Authorized Official - Phone:770-478-1099
Mailing Address - Street 1:853 BATTLECREEK RD
Mailing Address - Street 2:
Mailing Address - City:JONESBORO
Mailing Address - State:GA
Mailing Address - Zip Code:30236-1919
Mailing Address - Country:US
Mailing Address - Phone:770-478-1099
Mailing Address - Fax:770-603-4797
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:770-603-4797
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-06-12
Last Update Date:2012-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAAPC002869251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health