Provider Demographics
NPI:1114075678
Name:REESE, MARY KATE (PHD, LPC)
Entity Type:Individual
Prefix:DR
First Name:MARY KATE
Middle Name:
Last Name:REESE
Suffix:
Gender:F
Credentials:PHD, LPC
Other - Prefix:MS
Other - First Name:MARY KATE
Other - Middle Name:
Other - Last Name:BAGWELL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:490 SUN VALLEY DR
Mailing Address - Street 2:SUITE 205
Mailing Address - City:ROSWELL
Mailing Address - State:GA
Mailing Address - Zip Code:30076-5615
Mailing Address - Country:US
Mailing Address - Phone:770-642-4236
Mailing Address - Fax:770-642-4239
Practice Address - Street 1:490 SUN VALLEY DR
Practice Address - Street 2:SUITE 205
Practice Address - City:ROSWELL
Practice Address - State:GA
Practice Address - Zip Code:30076-5615
Practice Address - Country:US
Practice Address - Phone:770-642-4236
Practice Address - Fax:770-642-4239
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA1425101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional