Provider Demographics
NPI:1437285301
Name:TOLLESON, MARY KATHRYN (MS)
Entity Type:Individual
Prefix:MS
First Name:MARY
Middle Name:KATHRYN
Last Name:TOLLESON
Suffix:
Gender:F
Credentials:MS
Other - Prefix:MS
Other - First Name:KATIE
Other - Middle Name:
Other - Last Name:TOLLESON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MS
Mailing Address - Street 1:2086 GOLFVIEW DR NW
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30309-1210
Mailing Address - Country:US
Mailing Address - Phone:404-386-8849
Mailing Address - Fax:
Practice Address - Street 1:6000 LAKE FORREST DR STE 520
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30328-3879
Practice Address - Country:US
Practice Address - Phone:404-386-8849
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-26
Last Update Date:2021-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA4333101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA01-0845989OtherEIN