Provider Demographics
NPI:1447768106
Name:ANDERSON, MARY GRACE D (LAPC)
Entity Type:Individual
Prefix:
First Name:MARY GRACE
Middle Name:D
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:LAPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2090 SUGARLOAF PKWY STE 115
Mailing Address - Street 2:
Mailing Address - City:LAWRENCEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30045-9402
Mailing Address - Country:US
Mailing Address - Phone:770-676-0589
Mailing Address - Fax:
Practice Address - Street 1:2090 SUGARLOAF PKWY STE 115
Practice Address - Street 2:
Practice Address - City:LAWRENCEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30045-9402
Practice Address - Country:US
Practice Address - Phone:770-676-0589
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-01-16
Last Update Date:2023-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAAPC006172101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional