1689995011 NPI number — MS. MARY ELIZABETH PEDERSON LPC, M.ED., ED.S.

Table of content: MS. MARY ELIZABETH PEDERSON LPC, M.ED., ED.S. (NPI 1689995011)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1689995011 NPI number — MS. MARY ELIZABETH PEDERSON LPC, M.ED., ED.S.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PEDERSON
Provider First Name:
MARY
Provider Middle Name:
ELIZABETH
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
LPC, M.ED., ED.S.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1689995011
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/06/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2775 CRUSE RD STE 1601
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LAWRENCEVILLE
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30044-7145
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
678-620-3204
Provider Business Mailing Address Fax Number:
770-559-4232

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2775 CRUSE RD STE 1601
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LAWRENCEVILLE
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30044-7145
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
678-620-3204
Provider Business Practice Location Address Fax Number:
770-559-4232
Provider Enumeration Date:
06/21/2010

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 101YP2500X , with the licence number:  LPC004631 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: LPC004631 . This is a "LPC OF GEORGIA" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".




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