MEDICARE: DR. SUSAN ELLIS CHANCE PHD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103T00000X	Psychologist	PSY00079	GA
2	103TC0700X	Clinical Psychologist	PSY00079	GA

General Provider Information

NPI Number	:	1508551128
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. SUSAN ELLIS CHANCE PHD

Provider Business Mailing Address
First Line	:	18 LENOX POINTE NE STE A
Second Line	:
City	:	ATLANTA
State	:	GA
Zip	:	30324-7402
Country	:	US
Telephone Number	:	404-966-8395
Fax Number	:

Provider Business Practice Location Address
First Line	:	18 LENOX POINTE NE STE A
Second Line	:
City	:	ATLANTA
State	:	GA
Zip	:	30324-7402
Country	:	US
Telephone Number	:	404-966-8395
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/10/2023
Last Update Date	:	04/10/2023

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