Provider Demographics
NPI:1356440119
Name:CONNETT, MARY ELLEN
Entity type:Individual
Prefix:
First Name:MARY ELLEN
Middle Name:
Last Name:CONNETT
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 1:3575 MACON RD
Mailing Address - Street 2:SUITE 13
Mailing Address - City:COLUMBUS
Mailing Address - State:GA
Mailing Address - Zip Code:31907-8200
Mailing Address - Country:US
Mailing Address - Phone:706-565-6062
Mailing Address - Fax:706-565-6160
Practice Address - Street 1:3575 MACON RD
Practice Address - Street 2:SUITE 13
Practice Address - City:COLUMBUS
Practice Address - State:GA
Practice Address - Zip Code:31907-8200
Practice Address - Country:US
Practice Address - Phone:706-565-6062
Practice Address - Fax:706-565-6160
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist