Provider Demographics
NPI:1386922623
Name:SANTIAGO, STACY LYN (MS, APC)
Entity type:Individual
Prefix:
First Name:STACY
Middle Name:LYN
Last Name:SANTIAGO
Suffix:
Gender:F
Credentials:MS, APC
Other - Prefix:
Other - First Name:STACY
Other - Middle Name:LYN
Other - Last Name:SMYK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MS, APC
Mailing Address - Street 1:1640 POWERS FERRY RD SE
Mailing Address - Street 2:BUILDING 9, SUITE 100
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30067-5491
Mailing Address - Country:US
Mailing Address - Phone:770-953-0080
Mailing Address - Fax:770-953-0031
Practice Address - Street 1:1640 POWERS FERRY RD SE
Practice Address - Street 2:BUILDING 9, SUITE 100
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30067-5491
Practice Address - Country:US
Practice Address - Phone:770-953-0080
Practice Address - Fax:770-953-0031
Is Sole Proprietor?:No
Enumeration Date:2011-08-03
Last Update Date:2011-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAAPC002534101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health