Healthcare Provider Details

I. General information

NPI: 1881815033
Provider Name (Legal Business Name): STEPHANIE ANNE MEDLIN LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/02/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5437 OXFORD CHASE WAY
DUNWOODY GA
30338
US

IV. Provider business mailing address

5437 OXFORD CHASE WAY
DUNWOODY GA
30338
US

V. Phone/Fax

Practice location:
  • Phone: 678-270-8386
  • Fax:
Mailing address:
  • Phone: 678-270-8386
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLCSW0000004515
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: