Provider Demographics
NPI:1992855431
Name:COOK, STACIE CHISOLM (LCSW)
Entity Type:Individual
Prefix:
First Name:STACIE
Middle Name:CHISOLM
Last Name:COOK
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:STACIE
Other - Middle Name:LEIGH
Other - Last Name:CHISOLM
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LCSW
Mailing Address - Street 1:560 MCKOY ST
Mailing Address - Street 2:
Mailing Address - City:DECATUR
Mailing Address - State:GA
Mailing Address - Zip Code:30030-4950
Mailing Address - Country:US
Mailing Address - Phone:404-438-2347
Mailing Address - Fax:
Practice Address - Street 1:560 MCKOY ST
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:GA
Practice Address - Zip Code:30030-4950
Practice Address - Country:US
Practice Address - Phone:404-438-2347
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-10
Last Update Date:2012-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA3508104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA633486737AMedicaid