Provider Demographics
NPI:1336617786
Name:BEISE, CASEY MINTZ (LCSW)
Entity Type:Individual
Prefix:MRS
First Name:CASEY
Middle Name:MINTZ
Last Name:BEISE
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 1:1479 BROCKETT RD STE 100
Mailing Address - Street 2:
Mailing Address - City:TUCKER
Mailing Address - State:GA
Mailing Address - Zip Code:30084-7326
Mailing Address - Country:US
Mailing Address - Phone:770-375-8124
Mailing Address - Fax:
Practice Address - Street 1:1479 BROCKETT RD STE 100
Practice Address - Street 2:
Practice Address - City:TUCKER
Practice Address - State:GA
Practice Address - Zip Code:30084-7326
Practice Address - Country:US
Practice Address - Phone:770-375-8124
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-11-04
Last Update Date:2018-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACSW0065561041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GACSW006556OtherGEORGIA COMPOSITE BOARD OF PC, SW, AND MFT CLINICAL SOCIAL WORKER