CLAYTON MHDDAD

Provider Demographics

• NPI: 1548458441
• Name: CLAYTON MHDDAD
• Entity type: Organization
• Organization Name: CLAYTON MHDDAD
• Other - Org Name: <UNAVAIL>
• Authorized Official - Title/Position: EXECUTIVE DIRECTOR
• Authorized Official - Prefix: MR
• Authorized Official - First Name: TERRY
• Authorized Official - Last Name: COLE
• Authorized Official - Phone: 770-478-2280
• Mailing Address - Street 1: 157 SMITH ST
• 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: 157 SMITH ST
• Practice Address - City: JONESBORO
• Practice Address - State: GA
• Practice Address - Zip Code: 30236-3546
• Practice Address - Country: US
• Practice Address - Phone: 770-478-2280
• Practice Address - Fax: 770-477-9772
• EIN: <UNAVAIL>
• Is Organization Subpart?: Yes
• Parent Organization LBN: CLAYTON MHDDAD
• Parent Organization TIN: <UNAVAIL>
• Enumeration Date: 2007-10-05
• Last Update Date: 2011-11-08

Provider Taxonomies

Primary?	Code	Type	Classification	Specialization	Group
Yes	251C00000X	Agencies	Day Training, Developmentally Disabled Services
No	251S00000X	Agencies	Community/Behavioral Health		Group - Multi-Specialty
No	261Q00000X	Ambulatory Health Care Facilities	Clinic/Center		Group - Multi-Specialty
No	101Y00000X	Behavioral Health & Social Service Providers	Counselor		Group - Multi-Specialty
No	103T00000X	Behavioral Health & Social Service Providers	Psychologist		Group - Multi-Specialty
No	261QM0801X	Ambulatory Health Care Facilities	Clinic/Center	Mental Health (Including Community Mental Health Center)	Group - Multi-Specialty

Provider Identifiers

State	Identifier ID	ID Type	Issuer
GA	00604205D	Medicaid
GA	00881218A	Medicaid
GA	00586176F	Medicaid
GA	00626249C	Medicaid
GA	00884056A	Medicaid
GA	00606922B	Medicaid
GA	00586176F	Medicaid
GA	26BDD2H	Medicare PIN