Provider Demographics
NPI:1407425093
Name:WHITE, STEPHANIE TAYLOR
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:TAYLOR
Last Name:WHITE
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 1:4730 ALLISON DR
Mailing Address - Street 2:
Mailing Address - City:SUGAR HILL
Mailing Address - State:GA
Mailing Address - Zip Code:30518-6253
Mailing Address - Country:US
Mailing Address - Phone:678-770-4263
Mailing Address - Fax:
Practice Address - Street 1:4080 MCGINNIS FERRY RD
Practice Address - Street 2:
Practice Address - City:ALPHARETTA
Practice Address - State:GA
Practice Address - Zip Code:30005-3948
Practice Address - Country:US
Practice Address - Phone:678-770-4263
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-18
Last Update Date:2021-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician