=====================================================
General NPI Number Information
=====================================================
NPI Number | 1689995011
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MARY ELIZABETH PEDERSON LPC, M.ED., ED.S.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/21/2010
-----------------------------------------------------
Last Update Date | 03/06/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2775 CRUSE RD STE 1601
-----------------------------------------------------
City | LAWRENCEVILLE
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30044-7145
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 678-620-3204
-----------------------------------------------------
Fax | 770-559-4232
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2775 CRUSE RD STE 1601
-----------------------------------------------------
City | LAWRENCEVILLE
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30044-7145
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 678-620-3204
-----------------------------------------------------
Fax | 770-559-4232
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number | LPC004631
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------