Healthcare Provider Details

I. General information

NPI: 1811194723
Provider Name (Legal Business Name): MARY GAGE DAVIDSON PH.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/03/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1904 MONROE DR NE STE. 120
ATLANTA GA
30324-4858
US

IV. Provider business mailing address

6140 LENOX PARK CIR NE
ATLANTA GA
30319-5365
US

V. Phone/Fax

Practice location:
  • Phone: 404-935-8385
  • Fax: 404-874-2020
Mailing address:
  • Phone: 404-935-8385
  • Fax: 404-874-2020

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number2036
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: