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General NPI Number Information
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NPI Number | 1821212341
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Entity Type | Organization
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Legal Business Name | STEPHANIE L. EZUST, PH.D., PC
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Dates
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Enumeration Date | 04/13/2007
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Last Update Date | 02/27/2020
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Provider Practice Location Address
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Address Line | 1348 PONCE DE LEON AVE NE
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City | ATLANTA
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State | GA
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Zip | 30306-4604
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Country | US
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Telephone | 404-371-9171
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Fax | 404-371-9172
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Provider Business Mailing Address
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Address Line | PO BOX 1192
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City | DECATUR
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State | GA
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Zip | 30031-1192
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Country | US
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Telephone | 404-371-9171
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Fax | 404-371-9172
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Authorized Official
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Title or Position | OWNER
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Name | DR. STEPHANIE L. EZUST
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Credential | PH.D.
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Telephone | 404-371-9171
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103TC0700X
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Taxonomy Name | Clinical Psychologist
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License Number | 1513
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License Number State | GA
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