MEDICARE: DEIDRA L MAYS LPC

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	101YP2500X	Professional Counselor	2995	LA
2	106H00000X	Marriage & Family Therapist	989	LA
3	101YP2500X	Professional Counselor	LPC004421	GA

General Provider Information

NPI Number	:	1760417539
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DEIDRA L MAYS LPC

Provider Business Mailing Address
First Line	:	PO BOX 391772
Second Line	:
City	:	SNELLVILLE
State	:	GA
Zip	:	30039-0030
Country	:	US
Telephone Number	:	678-852-0265
Fax Number	:

Provider Business Practice Location Address
First Line	:	2330 SCENIC HWY S
Second Line	:
City	:	SNELLVILLE
State	:	GA
Zip	:	30078-3115
Country	:	US
Telephone Number	:	678-852-0265
Fax Number	:

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

Provider Enumeration Date	:	07/11/2006
Last Update Date	:	06/24/2019

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