Provider Demographics
NPI:1336612837
Name:GREY-GOOSMAN, STEPHANIE M (LPC, NCC)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:M
Last Name:GREY-GOOSMAN
Suffix:
Gender:F
Credentials:LPC, NCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:745 WILLOWWIND DR
Mailing Address - Street 2:
Mailing Address - City:LOGANVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30052-6602
Mailing Address - Country:US
Mailing Address - Phone:678-643-2486
Mailing Address - Fax:
Practice Address - Street 1:659 AUBURN AVE NE APT 228
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30312-1980
Practice Address - Country:US
Practice Address - Phone:678-562-1520
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-01-07
Last Update Date:2022-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALPC012658101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health