Provider Demographics
NPI:1295876928
Name:MERCER, MANDY KIMBALL (LCSW)
Entity type:Individual
Prefix:
First Name:MANDY
Middle Name:KIMBALL
Last Name:MERCER
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:175 EMERY HWY
Mailing Address - Street 2:
Mailing Address - City:MACON
Mailing Address - State:GA
Mailing Address - Zip Code:31217-3692
Mailing Address - Country:US
Mailing Address - Phone:478-803-7631
Mailing Address - Fax:478-751-4530
Practice Address - Street 1:175 EMERY HWY
Practice Address - Street 2:
Practice Address - City:MACON
Practice Address - State:GA
Practice Address - Zip Code:31217-3692
Practice Address - Country:US
Practice Address - Phone:478-803-7625
Practice Address - Fax:478-751-4530
Is Sole Proprietor?:No
Enumeration Date:2007-02-08
Last Update Date:2012-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAMSW003931104100000X
GACSW0040511041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
GACSW004051OtherLCSW