=====================================================
General NPI Number Information
=====================================================
NPI Number | 1841354768
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | DESMOND ORVILLE MAUL LMFT
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/22/2006
-----------------------------------------------------
Last Update Date | 11/10/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2012 EASTVIEW PKWY STE 400
-----------------------------------------------------
City | CONYERS
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30013-5701
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 770-679-0586
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2215 EXCHANGE PL SE STE A
-----------------------------------------------------
City | CONYERS
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30013-6723
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 770-679-0586
-----------------------------------------------------
Fax | 770-285-6325
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number | MFT000266
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 106H00000X
-----------------------------------------------------
Taxonomy Name | Marriage & Family Therapist
-----------------------------------------------------
License Number | MFT000266
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number | 01191
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------