Provider Demographics
NPI:1912730425
Name:MURRAY, MANDISA
Entity type:Individual
Prefix:
First Name:MANDISA
Middle Name:
Last Name:MURRAY
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 1:2905 CHASTAIN MEADOWS PKWY APT 8208
Mailing Address - Street 2:
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30066-3438
Mailing Address - Country:US
Mailing Address - Phone:240-426-9688
Mailing Address - Fax:
Practice Address - Street 1:2905 CHASTAIN MEADOWS PKWY APT 8208
Practice Address - Street 2:
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30066-3438
Practice Address - Country:US
Practice Address - Phone:240-426-9688
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-08-21
Last Update Date:2024-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician