Provider Demographics
NPI:1164030953
Name:GAUSE, SUSAN BLAIR (MSN, APRN, PMHNP-BC)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:BLAIR
Last Name:GAUSE
Suffix:
Gender:F
Credentials:MSN, APRN, PMHNP-BC
Other - Prefix:
Other - First Name:SUSAN
Other - Middle Name:
Other - Last Name:BLAIR
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:445 WINN WAY
Mailing Address - Street 2:
Mailing Address - City:DECATUR
Mailing Address - State:GA
Mailing Address - Zip Code:30030-1707
Mailing Address - Country:US
Mailing Address - Phone:404-508-7796
Mailing Address - Fax:
Practice Address - Street 1:207 VAN NESS
Practice Address - Street 2:
Practice Address - City:PEACHTREE CITY
Practice Address - State:GA
Practice Address - Zip Code:30269-2134
Practice Address - Country:US
Practice Address - Phone:305-896-6146
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-07-17
Last Update Date:2020-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA261236363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health