Healthcare Provider Details

I. General information

NPI: 1134367378
Provider Name (Legal Business Name): MAYO PSYCHOLOGICAL SERVICES, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/26/2009
Last Update Date: 05/28/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1640 POWERS FERRY RD SE BLDG. 17, STE. 350
MARIETTA GA
30067-5491
US

IV. Provider business mailing address

1640 POWERS FERRY RD SE BLDG. 17, STE. 350
MARIETTA GA
30067-5491
US

V. Phone/Fax

Practice location:
  • Phone: 770-956-9212
  • Fax: 770-956-9211
Mailing address:
  • Phone: 770-956-9212
  • Fax: 770-956-9211

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number1582
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number1582
License Number StateGA

VIII. Authorized Official

Name: DR. SUSAN LESLIE MAYO
Title or Position: PRESIDENT
Credential: PH.D.
Phone: 770-956-9212