Provider Demographics
NPI:1164545430
Name:BYRD, MARY A
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:A
Last Name:BYRD
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MOLLY
Other - Middle Name:
Other - Last Name:BYRD
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:106 MINNIE SHAW RD
Mailing Address - Street 2:
Mailing Address - City:ADEL
Mailing Address - State:GA
Mailing Address - Zip Code:31620-6050
Mailing Address - Country:US
Mailing Address - Phone:229-896-7822
Mailing Address - Fax:
Practice Address - Street 1:1102 SMITH AVE
Practice Address - Street 2:
Practice Address - City:THOMASVILLE
Practice Address - State:GA
Practice Address - Zip Code:31792-5739
Practice Address - Country:US
Practice Address - Phone:229-225-4335
Practice Address - Fax:229-225-4374
Is Sole Proprietor?:No
Enumeration Date:2007-04-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALPC003059101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional