Provider Demographics
NPI:1407273816
Name:STURDIVANT MILES, SUSAN NECOLE (LPC,NCC)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:NECOLE
Last Name:STURDIVANT MILES
Suffix:
Gender:F
Credentials:LPC,NCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5176 MAINSTREET PARK DR
Mailing Address - Street 2:
Mailing Address - City:STONE MOUNTAIN
Mailing Address - State:GA
Mailing Address - Zip Code:30088-2440
Mailing Address - Country:US
Mailing Address - Phone:706-587-9955
Mailing Address - Fax:
Practice Address - Street 1:5176 MAINSTREET PARK DR
Practice Address - Street 2:
Practice Address - City:STONE MOUNTAIN
Practice Address - State:GA
Practice Address - Zip Code:30088-2440
Practice Address - Country:US
Practice Address - Phone:706-587-9955
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-03-24
Last Update Date:2024-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
172V00000X
GALPC014502101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No172V00000XOther Service ProvidersCommunity Health Worker