=====================================================
General NPI Number Information
=====================================================
NPI Number | 1508946195
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MARY BETH SUMMERVILLE PH.D.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/17/2006
-----------------------------------------------------
Last Update Date | 06/29/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 680 DOUTHIT FERRY RD SUITE 106
-----------------------------------------------------
City | CARTERSVILLE
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30120-4150
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 770-334-8461
-----------------------------------------------------
Fax | 770-334-8624
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 680 DOUTHIT FERRY RD SUITE 106
-----------------------------------------------------
City | CARTERSVILLE
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30120-4150
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 770-334-8461
-----------------------------------------------------
Fax | 770-334-8624
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103TC0700X
-----------------------------------------------------
Taxonomy Name | Clinical Psychologist
-----------------------------------------------------
License Number | PSY001432
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------