Provider Demographics
NPI:1457493991
Name:BRUDER MATTSON, SUSAN (PHD)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:
Last Name:BRUDER MATTSON
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 1:11285 ELKINS RD
Mailing Address - Street 2:STE D4
Mailing Address - City:ROSWELL
Mailing Address - State:GA
Mailing Address - Zip Code:30076
Mailing Address - Country:US
Mailing Address - Phone:770-521-0511
Mailing Address - Fax:770-521-0512
Practice Address - Street 1:11285 ELKINS RD
Practice Address - Street 2:STE D4
Practice Address - City:ROSWELL
Practice Address - State:GA
Practice Address - Zip Code:30076
Practice Address - Country:US
Practice Address - Phone:770-521-0511
Practice Address - Fax:770-521-0512
Is Sole Proprietor?:No
Enumeration Date:2007-02-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPSY002322103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
P99102Medicare UPIN
GA68BBGHCMedicare ID - Type Unspecified