Provider Demographics
NPI:1003816935
Name:FULP-PYE, MARY (LCSW)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:FULP-PYE
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 3229
Mailing Address - Street 2:
Mailing Address - City:VALDOSTA
Mailing Address - State:GA
Mailing Address - Zip Code:31604-3229
Mailing Address - Country:US
Mailing Address - Phone:229-244-4200
Mailing Address - Fax:229-244-4995
Practice Address - Street 1:3541 N CROSSING CIR
Practice Address - Street 2:
Practice Address - City:VALDOSTA
Practice Address - State:GA
Practice Address - Zip Code:31602-1019
Practice Address - Country:US
Practice Address - Phone:229-244-4200
Practice Address - Fax:229-244-4995
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-21
Last Update Date:2010-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA0012111041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000974311BMedicaid
GA000974311BMedicaid
GA80BBFQGMedicare ID - Type Unspecified