Provider Demographics
NPI:1609054196
Name:CARLSON, MARY S GRIFFIN (PHD)
Entity Type:Individual
Prefix:DR
First Name:MARY
Middle Name:S GRIFFIN
Last Name:CARLSON
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:MRS
Other - First Name:MARY
Other - Middle Name:S
Other - Last Name:GRIFFIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:BSN MED
Mailing Address - Street 1:1106 PIEDMONT WAY
Mailing Address - Street 2:
Mailing Address - City:GAINESVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30501
Mailing Address - Country:US
Mailing Address - Phone:770-393-8964
Mailing Address - Fax:678-696-5171
Practice Address - Street 1:430 PRIOR ST. N.E.
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:GA
Practice Address - Zip Code:30501
Practice Address - Country:US
Practice Address - Phone:770-393-8964
Practice Address - Fax:678-696-5171
Is Sole Proprietor?:Yes
Enumeration Date:2008-02-06
Last Update Date:2015-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA000691106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist