Provider Demographics
NPI:1285007559
Name:STEWART, SUSAN
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:
Last Name:STEWART
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:SUSAN
Other - Middle Name:ANN
Other - Last Name:STEWART
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LAPC
Mailing Address - Street 1:270 CARPENTER DR
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30328-4931
Mailing Address - Country:US
Mailing Address - Phone:678-460-0345
Mailing Address - Fax:678-460-0350
Practice Address - Street 1:270 CARPENTER DR
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30328-4931
Practice Address - Country:US
Practice Address - Phone:678-460-0345
Practice Address - Fax:678-460-0350
Is Sole Proprietor?:Yes
Enumeration Date:2015-11-08
Last Update Date:2015-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAAPC005183101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health