Provider Demographics
NPI:1225162555
Name:ALEXANDER, MARY BLAYDES (LPC)
Entity Type:Individual
Prefix:MRS
First Name:MARY
Middle Name:BLAYDES
Last Name:ALEXANDER
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:200 E MEMORIAL DR
Mailing Address - Street 2:SUITE 6
Mailing Address - City:DALLAS
Mailing Address - State:GA
Mailing Address - Zip Code:30132-3811
Mailing Address - Country:US
Mailing Address - Phone:770-505-1431
Mailing Address - Fax:770-505-1431
Practice Address - Street 1:200 E MEMORIAL DR
Practice Address - Street 2:SUITE 6
Practice Address - City:DALLAS
Practice Address - State:GA
Practice Address - Zip Code:30132-3811
Practice Address - Country:US
Practice Address - Phone:770-505-1431
Practice Address - Fax:770-505-1431
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-16
Last Update Date:2021-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALPC003206101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA795105989AMedicaid