Provider Demographics
NPI:1407815491
Name:SOETY, ELIZABETH MARIE (PHD)
Entity Type:Individual
Prefix:DR
First Name:ELIZABETH
Middle Name:MARIE
Last Name:SOETY
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:102 GUNN RD
Mailing Address - Street 2:
Mailing Address - City:CENTERVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:31028-1706
Mailing Address - Country:US
Mailing Address - Phone:478-953-0088
Mailing Address - Fax:478-953-0093
Practice Address - Street 1:102 GUNN RD
Practice Address - Street 2:
Practice Address - City:CENTERVILLE
Practice Address - State:GA
Practice Address - Zip Code:31028
Practice Address - Country:US
Practice Address - Phone:478-953-0088
Practice Address - Fax:478-953-0093
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-20
Last Update Date:2018-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPSY002815103G00000X, 103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA52703377OtherBLUE CROSS BLUE SHIELD
GA358345266AMedicaid
GA52703377OtherBLUE CROSS BLUE SHIELD