=====================================================
General NPI Number Information
=====================================================
NPI Number | 1811194723
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MARY GAGE DAVIDSON PH.D.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/03/2007
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1904 MONROE DR NE STE. 120
-----------------------------------------------------
City | ATLANTA
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30324-4858
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 404-935-8385
-----------------------------------------------------
Fax | 404-874-2020
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6140 LENOX PARK CIR NE
-----------------------------------------------------
City | ATLANTA
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30319-5365
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 404-935-8385
-----------------------------------------------------
Fax | 404-874-2020
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103T00000X
-----------------------------------------------------
Taxonomy Name | Psychologist
-----------------------------------------------------
License Number | 2036
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------