Provider Demographics
NPI:1821060690
Name:HINES, MARY
Entity Type:Individual
Prefix:MS
First Name:MARY
Middle Name:
Last Name:HINES
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:968 FOXCROFT RD NW
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30327-2622
Mailing Address - Country:US
Mailing Address - Phone:404-231-4757
Mailing Address - Fax:404-816-6668
Practice Address - Street 1:968 FOXCROFT RD NW
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30327
Practice Address - Country:US
Practice Address - Phone:404-231-4757
Practice Address - Fax:404-816-6668
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-06
Last Update Date:2018-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALCSW 001165101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health