Provider Demographics
NPI:1780614636
Name:VOLENTINE, SUSAN Z (PHD)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:Z
Last Name:VOLENTINE
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:122 CHERRY ST NE
Mailing Address - Street 2:
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30060-7206
Mailing Address - Country:US
Mailing Address - Phone:770-427-2911
Mailing Address - Fax:770-509-9529
Practice Address - Street 1:122 CHERRY ST NE
Practice Address - Street 2:
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30060-7206
Practice Address - Country:US
Practice Address - Phone:770-427-2911
Practice Address - Fax:770-509-9529
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA1048103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00521243AMedicaid
GAR80098Medicare UPIN
GA00521243AMedicaid