Provider Demographics
NPI:1396829875
Name:MAHON, MARY ELISSA (PHD)
Entity Type:Individual
Prefix:DR
First Name:MARY
Middle Name:ELISSA
Last Name:MAHON
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:LISA
Other - Middle Name:
Other - Last Name:MAHON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:6065 LAKE FORREST DR NW
Mailing Address - Street 2:SUITE 150
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30328-3844
Mailing Address - Country:US
Mailing Address - Phone:404-256-3889
Mailing Address - Fax:770-579-1967
Practice Address - Street 1:6065 LAKE FORREST DR NW
Practice Address - Street 2:SUITE 150
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30328-3844
Practice Address - Country:US
Practice Address - Phone:404-256-3889
Practice Address - Fax:770-579-1967
Is Sole Proprietor?:No
Enumeration Date:2006-10-24
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPSY001528103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
R1291Medicare UPIN
GA68BBCTKMedicare PIN