Healthcare Provider Details

I. General information

NPI: 1811779911
Provider Name (Legal Business Name): SUSAN REINGOLD APC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: SHOSHI REINGOLD

II. Dates (important events)

Enumeration Date: 10/16/2023
Last Update Date: 11/22/2024
Certification Date: 11/22/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11111 HOUZE RD STE 225
ROSWELL GA
30076-5618
US

IV. Provider business mailing address

185 TRUEHEDGE TRCE
ROSWELL GA
30076-2948
US

V. Phone/Fax

Practice location:
  • Phone: 770-603-0123
  • Fax:
Mailing address:
  • Phone: 140-440-5242
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License NumberAPC009542
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberAPC009542
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: