Healthcare Provider Details

I. General information

NPI: 1992311419
Provider Name (Legal Business Name): KEVIN STEIN PHD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/21/2020
Last Update Date: 12/28/2020
Certification Date: 12/28/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

55 WHITCHER ST NE STE 420
MARIETTA GA
30060-1171
US

IV. Provider business mailing address

55 WHITCHER ST NE STE 420
MARIETTA GA
30060-1171
US

V. Phone/Fax

Practice location:
  • Phone: 770-514-6760
  • Fax: 770-794-8034
Mailing address:
  • Phone: 770-514-6760
  • Fax: 770-794-8034

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPSY002880
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: