Healthcare Provider Details

I. General information

NPI: 1205508025
Provider Name (Legal Business Name): MRS. MARY D ETAY
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/30/2021
Last Update Date: 09/30/2021
Certification Date: 09/30/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

341 PONCE DE LEON AVE NE
ATLANTA GA
30308-2012
US

IV. Provider business mailing address

341 PONCE DE LEON AVE NE
ATLANTA GA
30308-2012
US

V. Phone/Fax

Practice location:
  • Phone: 404-616-9988
  • Fax: 404-489-6594
Mailing address:
  • Phone: 404-616-9988
  • Fax: 404-489-6594

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041S0200X
TaxonomySchool Social Worker
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: