Provider Demographics
NPI:1649737180
Name:STEEN, SUSAN B
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:B
Last Name:STEEN
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 1:1809 LAKE DOUGLAS RD
Mailing Address - Street 2:
Mailing Address - City:BAINBRIDGE
Mailing Address - State:GA
Mailing Address - Zip Code:39819-5143
Mailing Address - Country:US
Mailing Address - Phone:229-254-1245
Mailing Address - Fax:
Practice Address - Street 1:1306 S SLAPPEY BLVD STE A
Practice Address - Street 2:
Practice Address - City:ALBANY
Practice Address - State:GA
Practice Address - Zip Code:31701-2635
Practice Address - Country:US
Practice Address - Phone:229-430-4213
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-02-20
Last Update Date:2019-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171M00000XOther Service ProvidersCase Manager/Care CoordinatorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA171M00000XMedicaid