Provider Demographics
NPI:1417331927
Name:WIESMAN, STEPHANIE ELIZABETH (MS, LMHC, LPC)
Entity Type:Individual
Prefix:MRS
First Name:STEPHANIE
Middle Name:ELIZABETH
Last Name:WIESMAN
Suffix:
Gender:F
Credentials:MS, LMHC, LPC
Other - Prefix:
Other - First Name:STEPHANIE
Other - Middle Name:ELIZABETH
Other - Last Name:FRADY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4024 ORCHARD HILL TER
Mailing Address - Street 2:
Mailing Address - City:STONE MOUNTAIN
Mailing Address - State:GA
Mailing Address - Zip Code:30083-1249
Mailing Address - Country:US
Mailing Address - Phone:404-387-2689
Mailing Address - Fax:
Practice Address - Street 1:1505 LILBURN STONE MOUNTAIN RD
Practice Address - Street 2:SUITE 235
Practice Address - City:STONE MOUNTAIN
Practice Address - State:GA
Practice Address - Zip Code:30087-1857
Practice Address - Country:US
Practice Address - Phone:404-387-2689
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-07-14
Last Update Date:2019-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAAPC004196101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health