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General NPI Number Information
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NPI Number | 1558644617
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Entity Type | Individual
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Provider Name | SUSAN F RUSSELL PHD,THD, L.AC.,LMSW
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Gender | Female
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Dates
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Enumeration Date | 09/26/2011
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Last Update Date | 09/26/2011
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Provider Practice Location Address
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Address Line | 4343 SHALLOWFORD RD SUITE H-5
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City | MARIETTA
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State | GA
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Zip | 30062-5023
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Country | US
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Telephone | 770-552-4155
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Fax | 770-552-4275
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Provider Business Mailing Address
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Address Line | 4343 SHALLOWFORD RD SUITE H-5
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City | MARIETTA
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State | GA
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Zip | 30062-5023
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Country | US
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Telephone | 770-552-4155
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Fax | 770-552-4275
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103TA0400X
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Taxonomy Name | Addiction (Substance Use Disorder) Psychologist
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License Number | 001798 LMSW
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License Number State | GA
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Taxonomy #2
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Taxonomy Code | 103TF0000X
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Taxonomy Name | Family Psychologist
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License Number | 1798 LMSW
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License Number State | GA
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Taxonomy #3
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Taxonomy Code | 171100000X
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Taxonomy Name | Acupuncturist
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License Number | 87
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License Number State | GA
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