Healthcare Provider Details

I. General information

NPI: 1811801228
Provider Name (Legal Business Name): MARY LOU BENNETT MARTIN MED
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/01/2026
Last Update Date: 10/01/2026
Certification Date: 10/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

104 PILGRIM VILLAGE DR STE 300
CUMMING GA
30040-9232
US

IV. Provider business mailing address

PO BOX 2038
CUMMING GA
30028-6038
US

V. Phone/Fax

Practice location:
  • Phone: 678-595-2020
  • Fax:
Mailing address:
  • Phone: 706-525-8303
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: