Provider Demographics
NPI:1619191665
Name:ROSS, MARY LOU (LMT)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:LOU
Last Name:ROSS
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4147 N QUAIL DR
Mailing Address - Street 2:
Mailing Address - City:DOUGLASVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30135-3844
Mailing Address - Country:US
Mailing Address - Phone:404-402-9985
Mailing Address - Fax:770-489-6961
Practice Address - Street 1:4147 N QUAIL DR
Practice Address - Street 2:
Practice Address - City:DOUGLASVILLE
Practice Address - State:GA
Practice Address - Zip Code:30135-3844
Practice Address - Country:US
Practice Address - Phone:404-402-9985
Practice Address - Fax:770-489-6961
Is Sole Proprietor?:No
Enumeration Date:2007-04-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAMT000186225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist