Provider Demographics
NPI:1679758429
Name:DECRUISE-OATES, MARY (PSYD)
Entity type:Individual
Prefix:DR
First Name:MARY
Middle Name:
Last Name:DECRUISE-OATES
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2086 JODECO RD # 1219
Mailing Address - Street 2:
Mailing Address - City:MCDONOUGH
Mailing Address - State:GA
Mailing Address - Zip Code:30253-5220
Mailing Address - Country:US
Mailing Address - Phone:478-284-3985
Mailing Address - Fax:
Practice Address - Street 1:2450 VINSON HWY SE
Practice Address - Street 2:
Practice Address - City:MILLEDGEVILLE
Practice Address - State:GA
Practice Address - Zip Code:31061-4881
Practice Address - Country:US
Practice Address - Phone:305-478-3985
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-12-28
Last Update Date:2024-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL7636103TC0700X
NY021513103TC0700X
NC4268103TC0700X
VA0810004038103TC0700X
AR20-06103TC0700X
GA3737103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Multi-Specialty