MEDICARE: DR. SUSAN K BERTELSON 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	PSY001564	GA

General Provider Information

NPI Number	:	1861543209
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. SUSAN K BERTELSON PHD

Provider Business Mailing Address
First Line	:	1864 INDEPENDENCE SQ
Second Line	:	SUITE A
City	:	DUNWOODY
State	:	GA
Zip	:	30338-5173
Country	:	US
Telephone Number	:	770-668-0350
Fax Number	:	770-668-0417

Provider Business Practice Location Address
First Line	:	1864 INDEPENDENCE SQ
Second Line	:	SUITE A
City	:	DUNWOODY
State	:	GA
Zip	:	30338-5173
Country	:	US
Telephone Number	:	770-668-0350
Fax Number	:	770-668-0417

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

Provider Enumeration Date	:	01/14/2007
Last Update Date	:	07/08/2007

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