Provider Demographics
NPI:1154971240
Name:STACY EKMARK, LLC
Entity type:Organization
Organization Name:STACY EKMARK, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:STACY
Authorized Official - Middle Name:
Authorized Official - Last Name:EKMARK
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:770-375-2143
Mailing Address - Street 1:1071 CAMBRIDGE SQ STE B
Mailing Address - Street 2:
Mailing Address - City:ALPHARETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30009-1843
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1071 CAMBRIDGE SQ STE B
Practice Address - Street 2:
Practice Address - City:ALPHARETTA
Practice Address - State:GA
Practice Address - Zip Code:30009-1843
Practice Address - Country:US
Practice Address - Phone:770-375-2143
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-09-19
Last Update Date:2019-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)