Provider Demographics
NPI:1942890751
Name:THOM, STEPHANIE (LAPC)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:
Last Name:THOM
Suffix:
Gender:F
Credentials:LAPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4120 MEDLOCK PARK DR
Mailing Address - Street 2:
Mailing Address - City:SNELLVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30039-8777
Mailing Address - Country:US
Mailing Address - Phone:678-427-9859
Mailing Address - Fax:
Practice Address - Street 1:2330 SCENIC HWY S STE 612
Practice Address - Street 2:
Practice Address - City:SNELLVILLE
Practice Address - State:GA
Practice Address - Zip Code:30078-3115
Practice Address - Country:US
Practice Address - Phone:404-490-1934
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-25
Last Update Date:2021-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA101YM0800X, 101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health