Provider Demographics
NPI:1417575507
Name:WITHERSPOON, STACY D
Entity Type:Individual
Prefix:
First Name:STACY
Middle Name:D
Last Name:WITHERSPOON
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 1:2300 W PARK PL STE 125
Mailing Address - Street 2:
Mailing Address - City:STONE MOUNTAIN
Mailing Address - State:GA
Mailing Address - Zip Code:30087-3561
Mailing Address - Country:US
Mailing Address - Phone:678-330-1400
Mailing Address - Fax:
Practice Address - Street 1:2300 W PARK PL
Practice Address - Street 2:
Practice Address - City:STONE MOUNTAIN
Practice Address - State:GA
Practice Address - Zip Code:30087-6713
Practice Address - Country:US
Practice Address - Phone:678-330-1400
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-07-06
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Single Specialty