Provider Demographics
NPI:1114761962
Name:HARRIS, STACY ANN
Entity type:Individual
Prefix:
First Name:STACY
Middle Name:ANN
Last Name:HARRIS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:271 BIG RIDGE RD
Mailing Address - Street 2:
Mailing Address - City:TALKING ROCK
Mailing Address - State:GA
Mailing Address - Zip Code:30175-4604
Mailing Address - Country:US
Mailing Address - Phone:678-779-4223
Mailing Address - Fax:
Practice Address - Street 1:630 E CHURCH ST
Practice Address - Street 2:
Practice Address - City:JASPER
Practice Address - State:GA
Practice Address - Zip Code:30143-1312
Practice Address - Country:US
Practice Address - Phone:678-779-4223
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-06-25
Last Update Date:2024-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAMSW001906101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health