Provider Demographics
NPI:1811779911
Name:REINGOLD, SUSAN (APC)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:
Last Name:REINGOLD
Suffix:
Gender:F
Credentials:APC
Other - Prefix:
Other - First Name:SHOSHI
Other - Middle Name:
Other - Last Name:REINGOLD
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:185 TRUEHEDGE TRCE
Mailing Address - Street 2:
Mailing Address - City:ROSWELL
Mailing Address - State:GA
Mailing Address - Zip Code:30076-2948
Mailing Address - Country:US
Mailing Address - Phone:140-440-5242
Mailing Address - Fax:
Practice Address - Street 1:11111 HOUZE RD STE 225
Practice Address - Street 2:
Practice Address - City:ROSWELL
Practice Address - State:GA
Practice Address - Zip Code:30076-5618
Practice Address - Country:US
Practice Address - Phone:770-603-0123
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-10-16
Last Update Date:2024-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAAPC009542101Y00000X, 101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101Y00000XBehavioral Health & Social Service ProvidersCounselorGroup - Single Specialty