Provider Demographics
NPI:1508946195
Name:SUMMERVILLE, MARY BETH (PHD)
Entity Type:Individual
Prefix:DR
First Name:MARY
Middle Name:BETH
Last Name:SUMMERVILLE
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Mailing Address - Street 1:680 DOUTHIT FERRY RD
Mailing Address - Street 2:SUITE 106
Mailing Address - City:CARTERSVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30120-4150
Mailing Address - Country:US
Mailing Address - Phone:770-334-8461
Mailing Address - Fax:770-334-8624
Practice Address - Street 1:680 DOUTHIT FERRY RD
Practice Address - Street 2:SUITE 106
Practice Address - City:CARTERSVILLE
Practice Address - State:GA
Practice Address - Zip Code:30120-4150
Practice Address - Country:US
Practice Address - Phone:770-334-8461
Practice Address - Fax:770-334-8624
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-17
Last Update Date:2012-06-29
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
GAPSY001432103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000462294DMedicaid
GAR80945Medicare UPIN
GA000462294DMedicaid