Provider Demographics
NPI:1962973529
Name:STAIR, MARIELLE A (LCSW)
Entity type:Individual
Prefix:
First Name:MARIELLE
Middle Name:A
Last Name:STAIR
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 HUNTINGTON RD STE 101
Mailing Address - Street 2:
Mailing Address - City:ATHENS
Mailing Address - State:GA
Mailing Address - Zip Code:30606-7205
Mailing Address - Country:US
Mailing Address - Phone:706-514-1213
Mailing Address - Fax:706-504-9549
Practice Address - Street 1:1 HUNTINGTON RD STE 101
Practice Address - Street 2:
Practice Address - City:ATHENS
Practice Address - State:GA
Practice Address - Zip Code:30606-7205
Practice Address - Country:US
Practice Address - Phone:706-514-1213
Practice Address - Fax:706-504-9549
Is Sole Proprietor?:Yes
Enumeration Date:2018-12-07
Last Update Date:2020-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
GACSW006527OtherGA BOARD OF PROF. COUNSELORS, SOCIAL WORKERS, AND MARRIAGE & FAMILY THERAPISTS