Provider Demographics
NPI:1982813309
Name:DEKALB COMMUNITY SERVICE BOARD
Entity Type:Organization
Organization Name:DEKALB COMMUNITY SERVICE BOARD
Other - Org Name:NORTH DEKALB MENTAL HEALTH CENTER
Other - Org Type:Other Name
Authorized Official - Title/Position:COO
Authorized Official - Prefix:
Authorized Official - First Name:FABIO
Authorized Official - Middle Name:BRUNO
Authorized Official - Last Name:VAN DER MERWE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:404-294-3836
Mailing Address - Street 1:445 WINN WAY
Mailing Address - Street 2:
Mailing Address - City:DECATUR
Mailing Address - State:GA
Mailing Address - Zip Code:30030-1707
Mailing Address - Country:US
Mailing Address - Phone:404-508-7796
Mailing Address - Fax:
Practice Address - Street 1:3807 CLAIRMONT RD
Practice Address - Street 2:
Practice Address - City:CHAMBLEE
Practice Address - State:GA
Practice Address - Zip Code:30341-4911
Practice Address - Country:US
Practice Address - Phone:770-457-5867
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-22
Last Update Date:2020-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA000692261QM0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000692OtherLPC