=====================================================
General NPI Number Information
=====================================================
NPI Number | 1821613449
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SUZANNE STANLEY CACII
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/09/2020
-----------------------------------------------------
Last Update Date | 06/09/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2318 BROWNS BRIDGE RD
-----------------------------------------------------
City | GAINESVILLE
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30504-6041
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 770-531-4950
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1283 WESSELL RD NW
-----------------------------------------------------
City | GAINESVILLE
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30501-2843
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 770-519-8387
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YA0400X
-----------------------------------------------------
Taxonomy Name | Addiction (Substance Use Disorder) Counselor
-----------------------------------------------------
License Number | 3408
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------