Provider Demographics
NPI:1902390057
Name:MACE, AMY SUE
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:SUE
Last Name:MACE
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 1:4641 ROSWELL RD STE A
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30342-3073
Mailing Address - Country:US
Mailing Address - Phone:404-474-0506
Mailing Address - Fax:
Practice Address - Street 1:4641 ROSWELL RD STE A
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30342-3073
Practice Address - Country:US
Practice Address - Phone:404-474-0506
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-06-20
Last Update Date:2018-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAOT007053225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist