Provider Demographics
NPI:1003117615
Name:THE MARY WASHINGTON ASSISTED LIVING HOME, INC
Entity Type:Organization
Organization Name:THE MARY WASHINGTON ASSISTED LIVING HOME, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MS
Authorized Official - First Name:TAWANA
Authorized Official - Middle Name:
Authorized Official - Last Name:GRAY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:770-469-0155
Mailing Address - Street 1:590 MOUNTAIN OAKS PKWY
Mailing Address - Street 2:
Mailing Address - City:STONE MOUNTAIN
Mailing Address - State:GA
Mailing Address - Zip Code:30087-4732
Mailing Address - Country:US
Mailing Address - Phone:770-469-0155
Mailing Address - Fax:770-469-0155
Practice Address - Street 1:590 MOUNTAIN OAKS PKWY
Practice Address - Street 2:
Practice Address - City:STONE MOUNTAIN
Practice Address - State:GA
Practice Address - Zip Code:30087-4732
Practice Address - Country:US
Practice Address - Phone:770-469-0155
Practice Address - Fax:770-469-0155
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-11-12
Last Update Date:2010-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA0440181413104A0625X, 3104A0630X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3104A0625XNursing & Custodial Care FacilitiesAssisted Living FacilityAssisted Living, Mental Illness
No3104A0630XNursing & Custodial Care FacilitiesAssisted Living FacilityAssisted Living, Behavioral Disturbances