Provider Demographics
NPI:1861861809
Name:BURKE, STACEY LAURA
Entity Type:Individual
Prefix:
First Name:STACEY
Middle Name:LAURA
Last Name:BURKE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:STACEY
Other - Middle Name:LAURA
Other - Last Name:WARSHOWSKY
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LCSW
Mailing Address - Street 1:4985 LOWER ROSWELL RD
Mailing Address - Street 2:BLDG 200
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30068-4337
Mailing Address - Country:US
Mailing Address - Phone:770-598-0132
Mailing Address - Fax:
Practice Address - Street 1:4985 LOWER ROSWELL RD
Practice Address - Street 2:BLDG 200
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30068-4337
Practice Address - Country:US
Practice Address - Phone:770-598-0132
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-09-21
Last Update Date:2015-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACSW0054121041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical