Stacy Garrett Wallace, LCSW

Primary specialty

Clinical Social WorkerTaxonomy code 1041C0700X

License

CSW002388 Issued in GA

Practice address

105 Saint Stephens CT
Tyrone, GA 30290-1716

Phone

(770) 378-9913

NPI assigned

Oct 13, 2022

Sex

Female

Sole proprietor

No

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 1

Addresses

Electronic endpoints 1

Medicare fee-for-service enrollment

Not listed in the public Medicare enrollment file

Medicare enrollment (NPD)

Not enrolled

State licenses

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1665619200000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1665619200000",
    "number": "1225754120",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "74 PRICE DR W",
            "city": "LOCUST GROVE",
            "state": "GA",
            "postal_code": "302482540",
            "telephone_number": "770-378-9913"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "105 SAINT STEPHENS CT",
            "city": "TYRONE",
            "state": "GA",
            "postal_code": "302901716",
            "telephone_number": "770-378-9913"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "WALLACE",
        "first_name": "STACY",
        "middle_name": "GARRETT",
        "name_prefix": "Mrs.",
        "credential": "LCSW",
        "sole_proprietor": "NO",
        "sex": "F",
        "enumeration_date": "2022-10-13",
        "last_updated": "2022-10-13",
        "certification_date": "2022-10-13",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "1041C0700X",
            "taxonomy_group": "",
            "desc": "Social Worker, Clinical",
            "state": "GA",
            "license": "CSW002388",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [
        {
            "endpointType": "CONNECT",
            "endpointTypeDescription": "CONNECT URL",
            "endpoint": "Epic",
            "affiliation": "Y",
            "affiliationName": "Premise health of tennessee",
            "use": "OTHER",
            "useDescription": "Other",
            "useOtherDescription": "Other",
            "contentType": "OTHER",
            "contentTypeDescription": "Other",
            "contentOtherDescription": "Other",
            "address_1": "105 Saint Stephens Ct",
            "city": "Tyrone",
            "state": "GA",
            "country_code": "US",
            "postal_code": "302901716",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "other_names": []
}

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• Clinical Social Worker in Tyrone, GA
• Providers in Tyrone, GA by specialty
• Clinical Social Worker in Georgia

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Oct 13, 2022; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.