Healthcare Provider Details

I. General information

NPI: 1508946195
Provider Name (Legal Business Name): MARY BETH SUMMERVILLE PH.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/17/2006
Last Update Date: 06/29/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

680 DOUTHIT FERRY RD SUITE 106
CARTERSVILLE GA
30120-4150
US

IV. Provider business mailing address

680 DOUTHIT FERRY RD SUITE 106
CARTERSVILLE GA
30120-4150
US

V. Phone/Fax

Practice location:
  • Phone: 770-334-8461
  • Fax: 770-334-8624
Mailing address:
  • Phone: 770-334-8461
  • Fax: 770-334-8624

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPSY001432
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: