Healthcare Provider Details

I. General information

NPI: 1003900796
Provider Name (Legal Business Name): SUSAN SPENCE LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/03/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

ONE DUNWOODY PARK SUITE140
ATLANTA GA
30338
US

IV. Provider business mailing address

ONE DUNWOODY PARK SUITE 140
ATLANTA GA
30338
US

V. Phone/Fax

Practice location:
  • Phone: 770-390-0008
  • Fax: 770-390-0877
Mailing address:
  • Phone: 770-390-0008
  • Fax: 770-390-0877

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberLPC000364
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: