Provider Demographics
NPI:1144757659
Name:STACK, MARY (LCSW)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:STACK
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3497 TULIP TREE LN
Mailing Address - Street 2:
Mailing Address - City:DULUTH
Mailing Address - State:GA
Mailing Address - Zip Code:30096-5332
Mailing Address - Country:US
Mailing Address - Phone:678-234-3685
Mailing Address - Fax:
Practice Address - Street 1:6624 JIMMY CARTER BLVD STE A
Practice Address - Street 2:
Practice Address - City:PEACHTREE CORNERS
Practice Address - State:GA
Practice Address - Zip Code:30071-1727
Practice Address - Country:US
Practice Address - Phone:770-743-0004
Practice Address - Fax:404-900-5453
Is Sole Proprietor?:Yes
Enumeration Date:2017-05-15
Last Update Date:2017-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CSW0045831041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical