Healthcare Provider Details

I. General information

NPI: 1609017912
Provider Name (Legal Business Name): SUSAN MARGARET LAIRD PH.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: SUSAN LAIRD PUCKETT

II. Dates (important events)

Enumeration Date: 03/16/2009
Last Update Date: 03/16/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

805 CHURCH ST
DECATUR GA
30030-1870
US

IV. Provider business mailing address

805 CHURCH ST
DECATUR GA
30030-1870
US

V. Phone/Fax

Practice location:
  • Phone: 404-617-1615
  • Fax:
Mailing address:
  • Phone: 404-617-1615
  • Fax: 404-377-6798

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License NumberPSY002247
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: