Provider Demographics
NPI:1740439546
Name:CARROLL, SUSAN P (CCC-SLP)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:P
Last Name:CARROLL
Suffix:
Gender:F
Credentials:CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5173 EASTBROOK RD
Mailing Address - Street 2:
Mailing Address - City:DOUGLASVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30135-7436
Mailing Address - Country:US
Mailing Address - Phone:404-403-9478
Mailing Address - Fax:770-977-1582
Practice Address - Street 1:5173 EASTBROOK RD
Practice Address - Street 2:
Practice Address - City:DOUGLASVILLE
Practice Address - State:GA
Practice Address - Zip Code:30135-7436
Practice Address - Country:US
Practice Address - Phone:404-403-9478
Practice Address - Fax:770-977-1582
Is Sole Proprietor?:Yes
Enumeration Date:2008-09-17
Last Update Date:2008-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GASLP000907235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist