Provider Demographics
NPI:1154984425
Name:MAYO, REGINA NICOLE
Entity type:Individual
Prefix:
First Name:REGINA
Middle Name:NICOLE
Last Name:MAYO
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 1:3651 PEACHTREE PKWYSTE
Mailing Address - Street 2:
Mailing Address - City:SUWANEE GA
Mailing Address - State:GA
Mailing Address - Zip Code:30024
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3040 HOLCOMB BRIDGE RD
Practice Address - Street 2:
Practice Address - City:NORCROSS
Practice Address - State:GA
Practice Address - Zip Code:30071-1377
Practice Address - Country:US
Practice Address - Phone:770-696-9231
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-22
Last Update Date:2019-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health