Provider Demographics
NPI:1851780118
Name:LANDRUM, STEPHANIE MARIE (MED, LPC, NCC)
Entity Type:Individual
Prefix:MRS
First Name:STEPHANIE
Middle Name:MARIE
Last Name:LANDRUM
Suffix:
Gender:F
Credentials:MED, LPC, NCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21 EASTBROOK BND STE 110
Mailing Address - Street 2:
Mailing Address - City:PEACHTREE CITY
Mailing Address - State:GA
Mailing Address - Zip Code:30269-1546
Mailing Address - Country:US
Mailing Address - Phone:770-741-2184
Mailing Address - Fax:770-215-0186
Practice Address - Street 1:21 EASTBROOK BND STE 110
Practice Address - Street 2:
Practice Address - City:PEACHTREE CITY
Practice Address - State:GA
Practice Address - Zip Code:30269-1546
Practice Address - Country:US
Practice Address - Phone:770-741-2184
Practice Address - Fax:770-215-0186
Is Sole Proprietor?:No
Enumeration Date:2015-01-09
Last Update Date:2024-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALPC009832101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
GALPC009832OtherLICENSED PROFESSIONAL COUNSELOR