Provider Demographics
NPI:1255836524
Name:RICHARDS, STACI LEEANN
Entity Type:Individual
Prefix:
First Name:STACI
Middle Name:LEEANN
Last Name:RICHARDS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:153 INDEPENDENCE DR
Mailing Address - Street 2:
Mailing Address - City:CARROLLTON
Mailing Address - State:GA
Mailing Address - Zip Code:30116-9000
Mailing Address - Country:US
Mailing Address - Phone:770-836-6678
Mailing Address - Fax:770-830-2266
Practice Address - Street 1:153 INDEPENDENCE DR
Practice Address - Street 2:
Practice Address - City:CARROLLTON
Practice Address - State:GA
Practice Address - Zip Code:30116-9000
Practice Address - Country:US
Practice Address - Phone:770-836-6678
Practice Address - Fax:770-830-2266
Is Sole Proprietor?:No
Enumeration Date:2018-03-28
Last Update Date:2018-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician