Healthcare Provider Details

I. General information

NPI: 1487366324
Provider Name (Legal Business Name): STACEY CHESTER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/22/2022
Last Update Date: 12/22/2022
Certification Date: 12/22/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

120 E TRINITY PL
DECATUR GA
30030-3302
US

IV. Provider business mailing address

740 SIDNEY MARCUS BLVD NE APT 8308
ATLANTA GA
30324-5603
US

V. Phone/Fax

Practice location:
  • Phone: 404-378-2300
  • Fax:
Mailing address:
  • Phone: 678-614-4672
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: