Healthcare Provider Details

I. General information

NPI: 1851497036
Provider Name (Legal Business Name): MARCY A STIDUM LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/15/2006
Last Update Date: 10/17/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

153 INDEPENDENCE DR
CARROLLTON GA
30116-9000
US

IV. Provider business mailing address

122 GORDON COMMERCIAL DR # C
LAGRANGE GA
30240-5740
US

V. Phone/Fax

Practice location:
  • Phone: 770-836-6678
  • Fax: 770-836-2266
Mailing address:
  • Phone: 706-845-4045
  • Fax: 706-845-4312

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberCSW003490
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: