Provider Demographics
NPI:1285932756
Name:CHARLES, STEPHANIE FELECIA (LPC)
Entity type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:FELECIA
Last Name:CHARLES
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 306
Mailing Address - Street 2:
Mailing Address - City:LOVEJOY
Mailing Address - State:GA
Mailing Address - Zip Code:30250-0306
Mailing Address - Country:US
Mailing Address - Phone:678-459-5294
Mailing Address - Fax:770-783-6538
Practice Address - Street 1:500 LANIER AVE W STE 408
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30214-7638
Practice Address - Country:US
Practice Address - Phone:678-459-5294
Practice Address - Fax:770-783-6538
Is Sole Proprietor?:Yes
Enumeration Date:2011-03-08
Last Update Date:2011-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALPC 005735101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional