Provider Demographics
NPI:1477564367
Name:STANLEY, CHASSIDY M (LCSW)
Entity Type:Individual
Prefix:
First Name:CHASSIDY
Middle Name:M
Last Name:STANLEY
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4364 SILVER PEAK PKWY
Mailing Address - Street 2:
Mailing Address - City:SUWANEE
Mailing Address - State:GA
Mailing Address - Zip Code:30024-4016
Mailing Address - Country:US
Mailing Address - Phone:770-362-3268
Mailing Address - Fax:
Practice Address - Street 1:705 JESSE JEWELL PKWY SE
Practice Address - Street 2:SUITE 175
Practice Address - City:GAINESVILLE
Practice Address - State:GA
Practice Address - Zip Code:30501-3867
Practice Address - Country:US
Practice Address - Phone:770-718-9790
Practice Address - Fax:770-718-5531
Is Sole Proprietor?:No
Enumeration Date:2006-08-10
Last Update Date:2017-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACSW0034691041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAGRP7811OtherMEDICARE B
GA392701029AMedicaid
GA392701029BMedicaid
GA80BBGFJMedicare ID - Type Unspecified
GA80BBGKVMedicare ID - Type UnspecifiedPPA
GA392701029BMedicaid