Provider Demographics
NPI:1841800620
Name:STANLEY, KESHIA (LCSW)
Entity Type:Individual
Prefix:
First Name:KESHIA
Middle Name:
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 1:4032 SHADED OASIS LN
Mailing Address - Street 2:
Mailing Address - City:VILLA RICA
Mailing Address - State:GA
Mailing Address - Zip Code:30180-6966
Mailing Address - Country:US
Mailing Address - Phone:256-426-7690
Mailing Address - Fax:
Practice Address - Street 1:1155 PERIMETER CTR
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30338-5463
Practice Address - Country:US
Practice Address - Phone:855-493-5523
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-05
Last Update Date:2020-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACSW0059931041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA14931025OtherCAQH