Provider Demographics
NPI:1750508370
Name:FERRELL, SUSAN DAUGHTRY (PHD)
Entity Type:Individual
Prefix:DR
First Name:SUSAN
Middle Name:DAUGHTRY
Last Name:FERRELL
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:PO BOX 1146
Mailing Address - Street 2:66 NORTH ROUNTREE STREET
Mailing Address - City:METTER
Mailing Address - State:GA
Mailing Address - Zip Code:30439-1146
Mailing Address - Country:US
Mailing Address - Phone:912-685-6259
Mailing Address - Fax:912-685-9871
Practice Address - Street 1:66 N ROUNTREE ST
Practice Address - Street 2:
Practice Address - City:METTER
Practice Address - State:GA
Practice Address - Zip Code:30439-4019
Practice Address - Country:US
Practice Address - Phone:912-685-6259
Practice Address - Fax:912-685-9871
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAGA001780103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00529119BMedicaid