Provider Demographics
NPI:1144303223
Name:GREATER ETOWAH MENTAL RETARDATION 310 BOARD, INC.
Entity type:Organization
Organization Name:GREATER ETOWAH MENTAL RETARDATION 310 BOARD, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:BARBARA
Authorized Official - Middle Name:S
Authorized Official - Last Name:CLACKUM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:256-546-6016
Mailing Address - Street 1:319 PADENREICH AVE
Mailing Address - Street 2:
Mailing Address - City:GADSDEN
Mailing Address - State:AL
Mailing Address - Zip Code:35903-2440
Mailing Address - Country:US
Mailing Address - Phone:256-546-6016
Mailing Address - Fax:256-546-6016
Practice Address - Street 1:319 PADENREICH AVE
Practice Address - Street 2:
Practice Address - City:GADSDEN
Practice Address - State:AL
Practice Address - Zip Code:35903-2440
Practice Address - Country:US
Practice Address - Phone:256-546-6016
Practice Address - Fax:256-546-6016
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-23
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251B00000XAgenciesCase Management