Provider Demographics
NPI:1588676654
Name:MAYO, SUSAN LESLIE (PHD)
Entity Type:Individual
Prefix:DR
First Name:SUSAN
Middle Name:LESLIE
Last Name:MAYO
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:MS
Other - First Name:SUSAN
Other - Middle Name:MAYO
Other - Last Name:CARVER
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:1640 POWERS FERRY RD SE
Mailing Address - Street 2:BLDG. 17, STE. 350
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30067-5491
Mailing Address - Country:US
Mailing Address - Phone:770-956-9212
Mailing Address - Fax:770-956-9211
Practice Address - Street 1:1640 POWERS FERRY RD SE
Practice Address - Street 2:BLDG. 17, STE. 350
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30067-5491
Practice Address - Country:US
Practice Address - Phone:770-956-9212
Practice Address - Fax:770-956-9211
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-13
Last Update Date:2013-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA1582103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA68BBFBCMedicare UPIN
GA68BBFBCMedicare ID - Type Unspecified