Healthcare Provider Details

I. General information

NPI: 1285723098
Provider Name (Legal Business Name): MARTHA (MOLLY) KEETON PARNELL PHD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/11/2006
Last Update Date: 09/16/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1945 MASON MILL RD SUITE 100
DECATUR GA
30033-4006
US

IV. Provider business mailing address

1945 MASON MILL RD SUITE 100
DECATUR GA
30033-4006
US

V. Phone/Fax

Practice location:
  • Phone: 404-215-4035
  • Fax: 404-321-4887
Mailing address:
  • Phone: 404-215-4035
  • Fax: 404-321-4887

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License NumberPSY 002746
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: