Provider Demographics
NPI:1245311299
Name:MAYO, SALLY L (PHD)
Entity type:Individual
Prefix:MS
First Name:SALLY
Middle Name:L
Last Name:MAYO
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:SALLY
Other - Middle Name:LEWIECKI
Other - Last Name:MAYO
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PHD
Mailing Address - Street 1:321 HOPE STREET
Mailing Address - Street 2:
Mailing Address - City:PROVIDENCE
Mailing Address - State:RI
Mailing Address - Zip Code:02906-2209
Mailing Address - Country:US
Mailing Address - Phone:401-421-1405
Mailing Address - Fax:401-331-8223
Practice Address - Street 1:321 HOPE STREET
Practice Address - Street 2:
Practice Address - City:PROVIDENCE
Practice Address - State:RI
Practice Address - Zip Code:02906-2209
Practice Address - Country:US
Practice Address - Phone:401-421-1405
Practice Address - Fax:401-331-8223
Is Sole Proprietor?:No
Enumeration Date:2006-10-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIPS00968103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
RI413620OtherCHP
RI413620OtherCHP