Provider Demographics
NPI:1962617183
Name:STEPHANIE LEEDY-ELLIS, PH.D., LLC
Entity type:Organization
Organization Name:STEPHANIE LEEDY-ELLIS, PH.D., LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:DR
Authorized Official - First Name:STEPHANIE
Authorized Official - Middle Name:
Authorized Official - Last Name:LEEDY-ELLIS
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:404-231-3364
Mailing Address - Street 1:3949 HOLCOMB BRIDGE RD
Mailing Address - Street 2:SUITE 200
Mailing Address - City:NORCROSS
Mailing Address - State:GA
Mailing Address - Zip Code:30092-2207
Mailing Address - Country:US
Mailing Address - Phone:404-231-3364
Mailing Address - Fax:770-813-7446
Practice Address - Street 1:3949 HOLCOMB BRIDGE RD
Practice Address - Street 2:SUITE 200
Practice Address - City:NORCROSS
Practice Address - State:GA
Practice Address - Zip Code:30092-2207
Practice Address - Country:US
Practice Address - Phone:404-231-3364
Practice Address - Fax:770-813-7446
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-11
Last Update Date:2011-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA1688103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA1447346101OtherINDIVIDUAL PROVIDER NPI