Healthcare Provider Details

I. General information

NPI: 1619007192
Provider Name (Legal Business Name): MARY LISA HUBER M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/06/2007
Last Update Date: 09/11/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3500 PIEDMONT RD NE SUITE 775
ATLANTA GA
30305-1507
US

IV. Provider business mailing address

3500 PIEDMONT RD NE SUITE 775
ATLANTA GA
30305-1507
US

V. Phone/Fax

Practice location:
  • Phone: 404-351-2008
  • Fax: 404-351-0243
Mailing address:
  • Phone: 404-351-2008
  • Fax: 404-351-0243

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberGA036399
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License NumberGA036399
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: