MEDICARE: MARA BLYTHE COLLINS LMFT

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	MFT001258	GA

General Provider Information

NPI Number	:	1629327580
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARA BLYTHE COLLINS LMFT

Provider Business Mailing Address
First Line	:	2937 KIMMERIDGE DR
Second Line	:
City	:	ATLANTA
State	:	GA
Zip	:	30344-6809
Country	:	US
Telephone Number	:	678-938-7677
Fax Number	:

Provider Business Practice Location Address
First Line	:	1189 EUCLID AVE NE
Second Line	:
City	:	ATLANTA
State	:	GA
Zip	:	30307-1509
Country	:	US
Telephone Number	:	404-522-9912
Fax Number	:

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

Provider Enumeration Date	:	09/06/2012
Last Update Date	:	07/10/2014

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