Healthcare Provider Details

I. General information

NPI: 1962973529
Provider Name (Legal Business Name): MARIELLE A STAIR LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/07/2018
Last Update Date: 06/25/2020
Certification Date: 06/25/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 HUNTINGTON RD STE 101
ATHENS GA
30606-7205
US

IV. Provider business mailing address

1 HUNTINGTON RD STE 101
ATHENS GA
30606-7205
US

V. Phone/Fax

Practice location:
  • Phone: 706-514-1213
  • Fax: 706-504-9549
Mailing address:
  • Phone: 706-514-1213
  • Fax: 706-504-9549

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: