Provider Demographics
| NPI: | 1649257791 |
|---|---|
| Name: | CLAYTON COMMUNITY MENTAL HEALTH SUBSTANCE AB |
| Entity type: | Organization |
| Organization Name: | CLAYTON COMMUNITY MENTAL HEALTH SUBSTANCE AB |
| Other - Org Name: | <UNAVAIL> |
| Other - Org Type: | |
| Authorized Official - Title/Position: | EXECUTIVE D IRECTOR |
| Authorized Official - Prefix: | |
| 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: | 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: | 770-478-2280 |
| Practice Address - Fax: | 770-477-9772 |
| EIN: | <UNAVAIL> |
| Is Organization Subpart?: | Yes |
| Parent Organization LBN: | CLAYTON COMMUNITY MENTAL HEALTH SUBSTANCE ABUSE DEVE SVCS |
| Parent Organization TIN: | <UNAVAIL> |
| Enumeration Date: | 2005-12-29 |
| Last Update Date: | 2011-11-15 |
| Deactivation Date: | |
| Deactivation Code: | |
| Reactivation Date: |
Provider Taxonomies
| Primary? | Code | Type | Classification | Specialization | Group |
|---|---|---|---|---|---|
| Yes | 261QM0801X | Ambulatory Health Care Facilities | Clinic/Center | Mental Health (Including Community Mental Health Center) | |
| No | 261QD1600X | Ambulatory Health Care Facilities | Clinic/Center | Developmental Disabilities | 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 | 103T00000X | Behavioral Health & Social Service Providers | Psychologist | Group - Multi-Specialty | |
| No | 103TA0400X | Behavioral Health & Social Service Providers | Psychologist | Addiction (Substance Use Disorder) | Group - Multi-Specialty |
| No | 103TB0200X | Behavioral Health & Social Service Providers | Psychologist | Cognitive & Behavioral | Group - Multi-Specialty |
| No | 104100000X | Behavioral Health & Social Service Providers | Social Worker | Group - Multi-Specialty | |
| No | 261QM0850X | Ambulatory Health Care Facilities | Clinic/Center | Adult Mental Health | |
| No | 251S00000X | Agencies | Community/Behavioral Health | ||
| No | 251C00000X | Agencies | Day Training, Developmentally Disabled Services | ||
| No | 261Q00000X | Ambulatory Health Care Facilities | Clinic/Center | ||
| No | 261QM0855X | Ambulatory Health Care Facilities | Clinic/Center | Adolescent and Children Mental Health |
Provider Identifiers
| State | Identifier ID | ID Type | Issuer |
|---|---|---|---|
| GA | GRP2322 | Other | CAHABA GBA |
| GA | 00604205E | Medicaid | |
| GA | D83380 | Medicare UPIN | |
| GA | 11BDWRJ | Medicare PIN | |
| GA | GRP2322 | Medicare PIN |
