Provider Demographics
NPI:1740309319
Name:GRESHAM, MARY (PHD)
Entity type:Individual
Prefix:DR
First Name:MARY
Middle Name:
Last Name:GRESHAM
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2801 BUFORD HWY NE STE 260
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30329-2137
Mailing Address - Country:US
Mailing Address - Phone:404-320-6510
Mailing Address - Fax:404-321-0311
Practice Address - Street 1:2801 BUFORD HWY NE STE 260
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30329-2137
Practice Address - Country:US
Practice Address - Phone:404-320-6510
Practice Address - Fax:404-321-0311
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA1204103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical