Provider Demographics
NPI:1134521180
Name:BETHEA, STACIE (MSW)
Entity type:Individual
Prefix:
First Name:STACIE
Middle Name:
Last Name:BETHEA
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:184 WILLOW SPRINGS LN
Mailing Address - Street 2:
Mailing Address - City:STOCKBRIDGE
Mailing Address - State:GA
Mailing Address - Zip Code:30281-6228
Mailing Address - Country:US
Mailing Address - Phone:917-848-5567
Mailing Address - Fax:404-564-6487
Practice Address - Street 1:2001 MARTIN LUTHER KING JR DR SW
Practice Address - Street 2:SUITE 409
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30310-1101
Practice Address - Country:US
Practice Address - Phone:404-564-6486
Practice Address - Fax:404-564-6487
Is Sole Proprietor?:No
Enumeration Date:2014-09-22
Last Update Date:2014-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA101Y00000X, 101YA0400X, 101YM0800X, 104100000X, 1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical