Provider Demographics
NPI:1891903530
Name:WALLER, SUZANNE (LPC)
Entity Type:Individual
Prefix:
First Name:SUZANNE
Middle Name:
Last Name:WALLER
Suffix:
Gender:F
Credentials:LPC
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 999
Mailing Address - Street 2:
Mailing Address - City:DAHLONEGA
Mailing Address - State:GA
Mailing Address - Zip Code:30533-0017
Mailing Address - Country:US
Mailing Address - Phone:770-598-4034
Mailing Address - Fax:706-865-0656
Practice Address - Street 1:309 PIRKLE FERRY RD
Practice Address - Street 2:A 400
Practice Address - City:CUMMING
Practice Address - State:GA
Practice Address - Zip Code:30040-2545
Practice Address - Country:US
Practice Address - Phone:770-598-4034
Practice Address - Fax:706-865-0656
Is Sole Proprietor?:No
Enumeration Date:2007-05-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALPC003440101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health