Provider Demographics
NPI:1447863477
Name:WEIGERT, MARY MACKENZIE (BS)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:MACKENZIE
Last Name:WEIGERT
Suffix:
Gender:F
Credentials:BS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:110 PIPEMAKERS CIR STE 116
Mailing Address - Street 2:
Mailing Address - City:POOLER
Mailing Address - State:GA
Mailing Address - Zip Code:31322-4168
Mailing Address - Country:US
Mailing Address - Phone:912-507-1553
Mailing Address - Fax:888-413-4567
Practice Address - Street 1:110 PIPEMAKERS CIR STE 116
Practice Address - Street 2:
Practice Address - City:POOLER
Practice Address - State:GA
Practice Address - Zip Code:31322-4168
Practice Address - Country:US
Practice Address - Phone:912-507-1553
Practice Address - Fax:888-413-4567
Is Sole Proprietor?:No
Enumeration Date:2020-08-28
Last Update Date:2022-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARBT-20-132859106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician