Healthcare Provider Details

I. General information

NPI: 1033834320
Provider Name (Legal Business Name): STEPHANIE MOYAL LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/10/2022
Last Update Date: 07/10/2023
Certification Date: 07/06/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 JOHNSON FERRY RD # 105
MARIETTA GA
30068-2114
US

IV. Provider business mailing address

1000 JOHNSON FERRY RD # 105
MARIETTA GA
30068-2114
US

V. Phone/Fax

Practice location:
  • Phone: 404-590-1004
  • Fax:
Mailing address:
  • Phone: 404-590-1004
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberCSW006210
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: