Provider Demographics
NPI:1528625357
Name:SOLOMON, SUSANA M (APC)
Entity type:Individual
Prefix:
First Name:SUSANA
Middle Name:M
Last Name:SOLOMON
Suffix:
Gender:F
Credentials:APC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:193 FAIROAKS CIR
Mailing Address - Street 2:
Mailing Address - City:STOCKBRIDGE
Mailing Address - State:GA
Mailing Address - Zip Code:30281-1191
Mailing Address - Country:US
Mailing Address - Phone:541-231-4423
Mailing Address - Fax:
Practice Address - Street 1:6020 DAWSON BLVD STE I
Practice Address - Street 2:
Practice Address - City:NORCROSS
Practice Address - State:GA
Practice Address - Zip Code:30093-1259
Practice Address - Country:US
Practice Address - Phone:541-231-4423
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-05-28
Last Update Date:2019-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAAPC006979OtherASSOCIATE PROFESSIONAL LICENSE