Provider Demographics
NPI:1063925600
Name:PRICE, STACIE (PSYD)
Entity type:Individual
Prefix:DR
First Name:STACIE
Middle Name:
Last Name:PRICE
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3364 MCEVER PARK CIR
Mailing Address - Street 2:
Mailing Address - City:ACWORTH
Mailing Address - State:GA
Mailing Address - Zip Code:30101-6648
Mailing Address - Country:US
Mailing Address - Phone:989-560-5707
Mailing Address - Fax:
Practice Address - Street 1:199 FRASIER ST SE
Practice Address - Street 2:
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30060-2201
Practice Address - Country:US
Practice Address - Phone:989-560-5707
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-11-06
Last Update Date:2017-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPSY04119103TF0200X, 103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103TF0200XBehavioral Health & Social Service ProvidersPsychologistForensic