Provider Demographics
NPI:1629616073
Name:STUART, MICHAEL TODD
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:TODD
Last Name:STUART
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:826 ASHTON PL
Mailing Address - Street 2:
Mailing Address - City:GRIFFIN
Mailing Address - State:GA
Mailing Address - Zip Code:30224-4850
Mailing Address - Country:US
Mailing Address - Phone:770-468-3718
Mailing Address - Fax:
Practice Address - Street 1:1435 N EXPRESSWAY
Practice Address - Street 2:
Practice Address - City:GRIFFIN
Practice Address - State:GA
Practice Address - Zip Code:30223-9016
Practice Address - Country:US
Practice Address - Phone:770-358-5252
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-12-17
Last Update Date:2019-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALPC010417101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAGA0494Medicaid