Provider Demographics
NPI:1033307731
Name:CLAYTON CENTER MHADDD
Entity type:Organization
Organization Name:CLAYTON CENTER MHADDD
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:DR
Authorized Official - First Name:AUNDRIA
Authorized Official - Middle Name:D
Authorized Official - Last Name:CHEEVER
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:770-478-2280
Mailing Address - Street 1:157 SMITH STREET
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 1:1396 SOUTHLAKE PLAZA DRIVE
Practice Address - Street 2:
Practice Address - City:MORROW
Practice Address - State:GA
Practice Address - Zip Code:30260-1756
Practice Address - Country:US
Practice Address - Phone:770-473-2640
Practice Address - Fax:770-473-2601
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CLAYTON CENTER COMMUNITY SERVICES BD
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-10-09
Last Update Date:2017-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA261QM0801X, 261QM0850X, 251B00000X, 251S00000X
261QM0801X, 261QM0850X, 251B00000X, 251S00000X, 101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes251S00000XAgenciesCommunity/Behavioral Health
No261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)Group - Multi-Specialty
No261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
No251B00000XAgenciesCase ManagementGroup - Multi-Specialty
No101Y00000XBehavioral Health & Social Service ProvidersCounselorGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000604205BMedicaid
GA00604205RMedicaid
GA68BBDKBMedicare PIN
GAGRP2322Medicare PIN