Provider Demographics
NPI:1851497036
Name:STIDUM, MARCY A (LCSW)
Entity Type:Individual
Prefix:MRS
First Name:MARCY
Middle Name:A
Last Name:STIDUM
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:122 GORDON COMMERCIAL DR # C
Mailing Address - Street 2:
Mailing Address - City:LAGRANGE
Mailing Address - State:GA
Mailing Address - Zip Code:30240-5740
Mailing Address - Country:US
Mailing Address - Phone:706-845-4045
Mailing Address - Fax:706-845-4312
Practice Address - Street 1:153 INDEPENDENCE DR
Practice Address - Street 2:
Practice Address - City:CARROLLTON
Practice Address - State:GA
Practice Address - Zip Code:30116-9000
Practice Address - Country:US
Practice Address - Phone:770-836-6678
Practice Address - Fax:770-836-2266
Is Sole Proprietor?:No
Enumeration Date:2006-09-15
Last Update Date:2007-10-17
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
GACSW0034901041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAQ53953Medicare UPIN