Provider Demographics
NPI:1134367378
Name:MAYO PSYCHOLOGICAL SERVICES, INC.
Entity type:Organization
Organization Name:MAYO PSYCHOLOGICAL SERVICES, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:LESLIE
Authorized Official - Last Name:MAYO
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:770-956-9212
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
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-01-26
Last Update Date:2013-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA1582251S00000X, 103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Multi-Specialty
No251S00000XAgenciesCommunity/Behavioral HealthGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA68BBFBCMedicare UPIN