Provider Demographics
NPI:1720284862
Name:MASCARO, NATHAN (PHD)
Entity Type:Individual
Prefix:
First Name:NATHAN
Middle Name:
Last Name:MASCARO
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:894 FIRESIDE WAY
Mailing Address - Street 2:
Mailing Address - City:STONE MOUNTAIN
Mailing Address - State:GA
Mailing Address - Zip Code:30083-2510
Mailing Address - Country:US
Mailing Address - Phone:404-558-5992
Mailing Address - Fax:
Practice Address - Street 1:3675 CRESTWOOD PKWY NW
Practice Address - Street 2:
Practice Address - City:DULUTH
Practice Address - State:GA
Practice Address - Zip Code:30096-1805
Practice Address - Country:US
Practice Address - Phone:404-558-5992
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA003091103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003091OtherPSYCHOLOGY LICENSE NUMBER