Provider Demographics
NPI:1386915767
Name:NEILL, MARY STUART (MED , LPC)
Entity type:Individual
Prefix:MS
First Name:MARY STUART
Middle Name:
Last Name:NEILL
Suffix:
Gender:F
Credentials:MED , LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9876 MAIN ST
Mailing Address - Street 2:SUITE 100
Mailing Address - City:WOODSTOCK
Mailing Address - State:GA
Mailing Address - Zip Code:30188-3970
Mailing Address - Country:US
Mailing Address - Phone:770-516-1050
Mailing Address - Fax:770-516-1300
Practice Address - Street 1:1427 ORANGE SHOALS DR
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:GA
Practice Address - Zip Code:30115-8554
Practice Address - Country:US
Practice Address - Phone:678-524-5241
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-01-18
Last Update Date:2012-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALPC003159101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional