| Stephanie L. Ezust, Ph.d., Pc | |
|
1348 Ponce De Leon Ave Ne Atlanta GA 30306-4604 | |
| (404) 371-9171 | |
| (404) 371-9172 |
| Full Name | Stephanie L. Ezust, Ph.d., Pc |
|---|---|
| Speciality | Psychologist |
| Location | 1348 Ponce De Leon Ave Ne, Atlanta, Georgia |
| Authorized Official Name and Position | Stephanie L. Ezust (OWNER) |
| Authorized Official Contact | 4043719171 |
| Accepts Medicare Insurance | Yes. This clinic participates in medicare program and accept medicare insurance. |
| Mailing Address | Practice Location Address |
|---|---|
| Stephanie L. Ezust, Ph.d., Pc Po Box 1192 Decatur GA 30031-1192 Ph: (404) 371-9171 | Stephanie L. Ezust, Ph.d., Pc 1348 Ponce De Leon Ave Ne Atlanta GA 30306-4604 Ph: (404) 371-9171 |
| NPI Number | 1821212341 |
|---|---|
| Provider Enumeration Date | 04/13/2007 |
| Last Update Date | 02/27/2020 |
| Certification Date | 02/27/2020 |
| Medicare PECOS PAC ID | 5193796951 |
|---|---|
| Medicare Enrollment ID | O20040804001019 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1821212341 | NPI | - | NPPES |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 103TC0700X | Psychologist - Clinical | 1513 (Georgia) | Primary |
| Provider Name | Stephanie L Ezust |
|---|---|
| Provider Type | Practitioner - Clinical Psychologist |
| Provider Identifiers | NPI Number: 1164589156 PECOS PAC ID: 3173595345 Enrollment ID: I20040809000620 |
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