Provider Demographics
NPI:1558644617
Name:RUSSELL, SUSAN F (PHD,THD, LAC,LMSW)
Entity Type:Individual
Prefix:DR
First Name:SUSAN
Middle Name:F
Last Name:RUSSELL
Suffix:
Gender:F
Credentials:PHD,THD, LAC,LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4343 SHALLOWFORD RD
Mailing Address - Street 2:SUITE H-5
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30062-5023
Mailing Address - Country:US
Mailing Address - Phone:770-552-4155
Mailing Address - Fax:770-552-4275
Practice Address - Street 1:4343 SHALLOWFORD RD
Practice Address - Street 2:SUITE H-5
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30062-5023
Practice Address - Country:US
Practice Address - Phone:770-552-4155
Practice Address - Fax:770-552-4275
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-26
Last Update Date:2011-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA001798 LMSW103TA0400X
GA1798 LMSW103TF0000X
GA87171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist
No103TA0400XBehavioral Health & Social Service ProvidersPsychologistAddiction (Substance Use Disorder)
No103TF0000XBehavioral Health & Social Service ProvidersPsychologistFamily