Healthcare Provider Details

I. General information

NPI: 1487043816
Provider Name (Legal Business Name): MARY ANN PEARSON LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/22/2015
Last Update Date: 01/22/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4530 S BERKELEY LAKE RD SUITE B
BERKELEY LAKE GA
30071-1660
US

IV. Provider business mailing address

4530 S BERKELEY LAKE RD SUITE B
BERKELEY LAKE GA
30071-1660
US

V. Phone/Fax

Practice location:
  • Phone: 470-514-3725
  • Fax: 770-446-5643
Mailing address:
  • Phone: 470-514-3725
  • Fax: 770-446-5643

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberLPC008013
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: