MEDICARE: MARY LANE GOULD-HARTLINE APRN BC CEDS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2084P0800X	Psychiatry Physician	1048511	AL

General Provider Information

NPI Number	:	1255387213
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARY LANE GOULD-HARTLINE APRN BC CEDS

Provider Business Mailing Address
First Line	:	2803 GREYSTONE COMMERCIAL BLVD STE 12
Second Line	:
City	:	HOOVER
State	:	AL
Zip	:	35242-9603
Country	:	US
Telephone Number	:	205-968-1227
Fax Number	:

Provider Business Practice Location Address
First Line	:	2803 GREYSTONE COMMERCIAL BLVD STE 12
Second Line	:
City	:	HOOVER
State	:	AL
Zip	:	35242-9603
Country	:	US
Telephone Number	:	205-968-1227
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/25/2006
Last Update Date	:	03/02/2022

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