Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 225XM0800X | Mental Health | OT004725 | GA |
NPI | 1609194091 |
---|---|
Provider Name | Susan Baizley |
First Address | Fort Stewart, GA 31314-5674 |
Second Address | Fort Stewar, GA 31314-5674 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 10/05/2010 |
Last Update Date | 07/09/2010 |