Healthcare Provider Details

I. General information

NPI: 1710513783
Provider Name (Legal Business Name): MARY L LOCKE MA, NCC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/20/2020
Last Update Date: 03/20/2020
Certification Date: 03/20/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

445 WINN WAY
DECATUR GA
30030-1707
US

IV. Provider business mailing address

1509 STONE GATE LN SE
ATLANTA GA
30317-2056
US

V. Phone/Fax

Practice location:
  • Phone: 470-508-6439
  • Fax:
Mailing address:
  • Phone: 912-656-0059
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number StateGA
# 3
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: