Provider Demographics
NPI:1356605760
Name:MAYHEW, THERESA MARIE (MA)
Entity type:Individual
Prefix:MRS
First Name:THERESA
Middle Name:MARIE
Last Name:MAYHEW
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:THERESA
Other - Middle Name:MARIE
Other - Last Name:KINTON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MA
Mailing Address - Street 1:PO BOX 62
Mailing Address - Street 2:
Mailing Address - City:YOUNG HARRIS
Mailing Address - State:GA
Mailing Address - Zip Code:30582-0062
Mailing Address - Country:US
Mailing Address - Phone:770-296-5175
Mailing Address - Fax:706-710-2355
Practice Address - Street 1:1114 MAIN ST
Practice Address - Street 2:
Practice Address - City:YOUNG HARRIS
Practice Address - State:GA
Practice Address - Zip Code:30582-3058
Practice Address - Country:US
Practice Address - Phone:770-296-5175
Practice Address - Fax:706-710-2355
Is Sole Proprietor?:No
Enumeration Date:2012-06-29
Last Update Date:2024-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALPC008594101YM0800X
101YP2500X, 101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101Y00000XBehavioral Health & Social Service ProvidersCounselor