Provider Demographics
NPI:1891071296
Name:RAULERSON, PHYLLIS SUSAN
Entity Type:Individual
Prefix:MRS
First Name:PHYLLIS
Middle Name:SUSAN
Last Name:RAULERSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5955 OWENS ROAD
Mailing Address - Street 2:
Mailing Address - City:PATTERSON
Mailing Address - State:GA
Mailing Address - Zip Code:31557
Mailing Address - Country:US
Mailing Address - Phone:912-449-6906
Mailing Address - Fax:912-449-4689
Practice Address - Street 1:5955 OWENS ROAD
Practice Address - Street 2:
Practice Address - City:PATTERSON
Practice Address - State:GA
Practice Address - Zip Code:31557
Practice Address - Country:US
Practice Address - Phone:912-449-6906
Practice Address - Fax:912-449-4689
Is Sole Proprietor?:Yes
Enumeration Date:2011-10-30
Last Update Date:2011-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA252Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes252Y00000XAgenciesEarly Intervention Provider Agency
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA257110638AMedicaid