Basic Information
| Provider Information | |||||||||
| NPI: | 1558767442 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BLANK | ||||||||
| FirstName: | SUSAN | ||||||||
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| Credential: | LPC, NCC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 284 S MAIN ST | ||||||||
| Address2: | SUITE 800 | ||||||||
| City: | ALPHARETTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 300097904 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6785754315 | ||||||||
| FaxNumber: | 4042500025 | ||||||||
| Practice Location | |||||||||
| Address1: | 755 MOUNT VERNON HWY NE | ||||||||
| Address2: | STE 330 | ||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303284274 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4042562277 | ||||||||
| FaxNumber: | 4042500025 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/05/2014 | ||||||||
| LastUpdateDate: | 07/06/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | LPC007811 | GA | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.