Provider Demographics
NPI:1154590073
Name:CLARK, SUSAN MARIE (PHD)
Entity type:Individual
Prefix:DR
First Name:SUSAN
Middle Name:MARIE
Last Name:CLARK
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 1:10 WILSON RD
Mailing Address - Street 2:
Mailing Address - City:STOCKBRIDGE
Mailing Address - State:GA
Mailing Address - Zip Code:30281-4468
Mailing Address - Country:US
Mailing Address - Phone:678-438-4225
Mailing Address - Fax:770-506-8663
Practice Address - Street 1:10 WILSON RD
Practice Address - Street 2:
Practice Address - City:STOCKBRIDGE
Practice Address - State:GA
Practice Address - Zip Code:30281-4468
Practice Address - Country:US
Practice Address - Phone:678-438-4225
Practice Address - Fax:770-506-8663
Is Sole Proprietor?:Yes
Enumeration Date:2008-02-25
Last Update Date:2009-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALPC005485101YP2500X, 101YM0800X, 101YP1600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YP1600XBehavioral Health & Social Service ProvidersCounselorPastoral