Provider Demographics
NPI:1417982190
Name:DAVIDSON, STEPHANIE WILDER (LCSW)
Entity Type:Individual
Prefix:MRS
First Name:STEPHANIE
Middle Name:WILDER
Last Name:DAVIDSON
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:MRS
Other - First Name:STEPHANIE
Other - Middle Name:WILDER
Other - Last Name:DAVIDSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LCSW
Mailing Address - Street 1:133 WILLOW LAKE DR
Mailing Address - Street 2:
Mailing Address - City:LEESBURG
Mailing Address - State:GA
Mailing Address - Zip Code:31763-5386
Mailing Address - Country:US
Mailing Address - Phone:229-886-8497
Mailing Address - Fax:
Practice Address - Street 1:133 WILLOW LAKE DR
Practice Address - Street 2:
Practice Address - City:LEESBURG
Practice Address - State:GA
Practice Address - Zip Code:31763-5386
Practice Address - Country:US
Practice Address - Phone:229-886-8497
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-11
Last Update Date:2008-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA0036231041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA1417982190OtherNPI NUMBER
GA381809514AMedicaid
GA1417982190OtherNPI NUMBER