Healthcare Provider Details

I. General information

NPI: 1659280535
Provider Name (Legal Business Name): KEONNA JANAY STANLEY
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/04/2026
Last Update Date: 09/04/2026
Certification Date: 09/04/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1030 FAYETTEVILLE RD SE
ATLANTA GA
30316-2921
US

IV. Provider business mailing address

7350 CAMPBELLTON RD SW APT 507
ATLANTA GA
30331-8180
US

V. Phone/Fax

Practice location:
  • Phone: 404-486-9034
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number251S00000X
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: