Healthcare Provider Details

I. General information

NPI: 1841398906
Provider Name (Legal Business Name): MARY G HALES M.A.,L.C.A.S,. L.P.C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/20/2006
Last Update Date: 10/28/2024
Certification Date: 10/28/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2375 MAIN ST NW APT 408
DULUTH GA
30097-2914
US

IV. Provider business mailing address

2375 MAIN ST NW APT 408
DULUTH GA
30097-2914
US

V. Phone/Fax

Practice location:
  • Phone: 716-465-1108
  • Fax:
Mailing address:
  • Phone: 716-465-1108
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number1707
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number0701006204
License Number StateVA
# 3
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number9378
License Number StateNC
# 4
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number008039
License Number StateGA
# 5
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberLCPC7200
License Number StateMD
# 6
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberPRC15050
License Number StateDC
# 7
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number0701006204
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: