Provider Demographics
NPI:1104958032
Name:STANLEY-SOULEN, MELANIE GRACE (MDIV)
Entity type:Individual
Prefix:MS
First Name:MELANIE
Middle Name:GRACE
Last Name:STANLEY-SOULEN
Suffix:
Gender:F
Credentials:MDIV
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:45 INLAND CIR
Mailing Address - Street 2:
Mailing Address - City:NEWNAN
Mailing Address - State:GA
Mailing Address - Zip Code:30263-5903
Mailing Address - Country:US
Mailing Address - Phone:678-378-8524
Mailing Address - Fax:770-253-1871
Practice Address - Street 1:576 ROSCOE RD
Practice Address - Street 2:
Practice Address - City:NEWNAN
Practice Address - State:GA
Practice Address - Zip Code:30263-4782
Practice Address - Country:US
Practice Address - Phone:678-378-8524
Practice Address - Fax:770-253-1871
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALPC003184101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional