Healthcare Provider Details

I. General information

NPI: 1588676654
Provider Name (Legal Business Name): SUSAN LESLIE MAYO PH.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: MS. SUSAN MAYO CARVER

II. Dates (important events)

Enumeration Date: 08/13/2006
Last Update Date: 05/22/2013
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 Code103TC1900X
TaxonomyCounseling Psychologist
License Number1582
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: