Provider Demographics
NPI:1902440340
Name:MOTLEY, MARK
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:MOTLEY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:501 MIZE ST
Mailing Address - Street 2:
Mailing Address - City:LA FAYETTE
Mailing Address - State:GA
Mailing Address - Zip Code:30728-3346
Mailing Address - Country:US
Mailing Address - Phone:706-638-5580
Mailing Address - Fax:
Practice Address - Street 1:2247 DUNWOODY RD
Practice Address - Street 2:
Practice Address - City:LA FAYETTE
Practice Address - State:GA
Practice Address - Zip Code:30728-6025
Practice Address - Country:US
Practice Address - Phone:423-991-0034
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-10-29
Last Update Date:2019-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health