MEDICARE: MARY ELLEN CONNETT

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	106H00000X	Marriage & Family Therapist		GA

General Provider Information

NPI Number	:	1356440119
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARY ELLEN CONNETT

Provider Business Mailing Address
First Line	:	3575 MACON RD
Second Line	:	SUITE 13
City	:	COLUMBUS
State	:	GA
Zip	:	31907-8200
Country	:	US
Telephone Number	:	706-565-6062
Fax Number	:	706-565-6160

Provider Business Practice Location Address
First Line	:	3575 MACON RD
Second Line	:	SUITE 13
City	:	COLUMBUS
State	:	GA
Zip	:	31907-8200
Country	:	US
Telephone Number	:	706-565-6062
Fax Number	:	706-565-6160

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

Provider Enumeration Date	:	09/21/2006
Last Update Date	:	07/08/2007

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Directions to “ MARY ELLEN CONNETT ” Practice Location

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