Provider Demographics
NPI:1821613449
Name:STANLEY, SUZANNE (CACII)
Entity Type:Individual
Prefix:
First Name:SUZANNE
Middle Name:
Last Name:STANLEY
Suffix:
Gender:F
Credentials:CACII
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1283 WESSELL RD NW
Mailing Address - Street 2:
Mailing Address - City:GAINESVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30501-2843
Mailing Address - Country:US
Mailing Address - Phone:770-519-8387
Mailing Address - Fax:
Practice Address - Street 1:2318 BROWNS BRIDGE RD
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:GA
Practice Address - Zip Code:30504-6041
Practice Address - Country:US
Practice Address - Phone:770-531-4950
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-06-09
Last Update Date:2020-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA3408101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA3408OtherSELF-PAY