Provider Demographics
NPI:1841696200
Name:MONGERSON, SUSAN
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:
Last Name:MONGERSON
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 1:1551 JENNINGS MILL RD UNIT 1700B
Mailing Address - Street 2:
Mailing Address - City:WATKINSVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30677-7266
Mailing Address - Country:US
Mailing Address - Phone:703-943-8442
Mailing Address - Fax:
Practice Address - Street 1:1551 JENNINGS MILL RD UNIT 1700B
Practice Address - Street 2:
Practice Address - City:WATKINSVILLE
Practice Address - State:GA
Practice Address - Zip Code:30677-7266
Practice Address - Country:US
Practice Address - Phone:703-943-8442
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-11-13
Last Update Date:2019-12-11
Deactivation Date:2019-08-06
Deactivation Code:
Reactivation Date:2019-11-18
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health