Provider Demographics
NPI:1104977412
Name:WOLFF, STACY L (LCSW)
Entity type:Individual
Prefix:
First Name:STACY
Middle Name:L
Last Name:WOLFF
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:487 MORRISON MOORE PKWY W
Mailing Address - Street 2:
Mailing Address - City:DAHLONEGA
Mailing Address - State:GA
Mailing Address - Zip Code:30533-1422
Mailing Address - Country:US
Mailing Address - Phone:706-344-8461
Mailing Address - Fax:706-348-6065
Practice Address - Street 1:487 MORRISON MOORE PKWY W
Practice Address - Street 2:
Practice Address - City:DAHLONEGA
Practice Address - State:GA
Practice Address - Zip Code:30533-1422
Practice Address - Country:US
Practice Address - Phone:706-344-8461
Practice Address - Fax:706-348-6065
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-15
Last Update Date:2009-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACSW0026511041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA374813915AMedicaid