Healthcare Provider Details

I. General information

NPI: 1932329646
Provider Name (Legal Business Name): MARY LOUISE SLULLIVAN R.D., LD, MA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/26/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2361 TOBACCO RD
AUGUSTA GA
30906-9220
US

IV. Provider business mailing address

3522 HILLTOP DR
AUGUSTA GA
30906-5732
US

V. Phone/Fax

Practice location:
  • Phone: 706-793-4401
  • Fax: 706-790-4372
Mailing address:
  • Phone: 706-796-8739
  • Fax: 706-796-6075

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License NumberLD000433
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: