Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 103TA0400X | Addiction Psychologist (Substance Use Disorder) | 001798 LMSW | GA |
N | 103TF0000X | Family Psychologist | 1798 LMSW | GA |
NPI | 1558644617 |
---|---|
Provider Name | Dr. Susan F Russell |
First Address | Marietta, GA 30062-5023 |
Second Address | Marietta, GA 30062-5023 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 26/09/2011 |
Last Update Date | 26/09/2011 |