Provider Demographics
NPI:1174110290
Name:PANASYUK, MARIAH LEE MARIE
Entity type:Individual
Prefix:
First Name:MARIAH
Middle Name:LEE MARIE
Last Name:PANASYUK
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 1:1715 FRIENDSHIP CIR STE 300
Mailing Address - Street 2:
Mailing Address - City:CUMMING
Mailing Address - State:GA
Mailing Address - Zip Code:30028-6920
Mailing Address - Country:US
Mailing Address - Phone:770-240-0163
Mailing Address - Fax:
Practice Address - Street 1:1715 FRIENDSHIP CIR STE 300
Practice Address - Street 2:
Practice Address - City:CUMMING
Practice Address - State:GA
Practice Address - Zip Code:30028-6920
Practice Address - Country:US
Practice Address - Phone:770-240-0163
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-12-22
Last Update Date:2020-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RBT-20--148381106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician