Provider Demographics
NPI:1487695144
Name:FAGES, SUSAN BETH (LIC-A)
Entity type:Individual
Prefix:MRS
First Name:SUSAN
Middle Name:BETH
Last Name:FAGES
Suffix:
Gender:F
Credentials:LIC-A
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2500 HOSPITAL BLVD
Mailing Address - Street 2:SUITE 450
Mailing Address - City:ROSWELL
Mailing Address - State:GA
Mailing Address - Zip Code:30076-4907
Mailing Address - Country:US
Mailing Address - Phone:770-343-8675
Mailing Address - Fax:770-343-8126
Practice Address - Street 1:2500 HOSPITAL BLVD
Practice Address - Street 2:SUITE 450
Practice Address - City:ROSWELL
Practice Address - State:GA
Practice Address - Zip Code:30076-4907
Practice Address - Country:US
Practice Address - Phone:770-343-8675
Practice Address - Fax:770-343-8126
Is Sole Proprietor?:No
Enumeration Date:2006-06-10
Last Update Date:2010-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA3457231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA64BCBPVMedicare PIN