Provider Demographics
NPI:1306196274
Name:BRYAN, SUSAN EVON
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:EVON
Last Name:BRYAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:SUSAN
Other - Middle Name:EVON
Other - Last Name:SCHOW
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:539 BARHAMS RIDGE DR
Mailing Address - Street 2:
Mailing Address - City:MCDONOUGH
Mailing Address - State:GA
Mailing Address - Zip Code:30252-5800
Mailing Address - Country:US
Mailing Address - Phone:770-876-9737
Mailing Address - Fax:
Practice Address - Street 1:539 BARHAMS RIDGE DR
Practice Address - Street 2:
Practice Address - City:MCDONOUGH
Practice Address - State:GA
Practice Address - Zip Code:30252-5800
Practice Address - Country:US
Practice Address - Phone:770-876-9737
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-09-18
Last Update Date:2012-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY201134574171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator