Provider Demographics
NPI:1144918699
Name:STOWELL, VIRGINIA JOHNSON
Entity type:Individual
Prefix:
First Name:VIRGINIA
Middle Name:JOHNSON
Last Name:STOWELL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1362 DUPONT PARK NW
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30318-2794
Mailing Address - Country:US
Mailing Address - Phone:205-242-4204
Mailing Address - Fax:
Practice Address - Street 1:317 W HILL ST STE 101
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:GA
Practice Address - Zip Code:30030-4368
Practice Address - Country:US
Practice Address - Phone:404-947-5764
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-04-24
Last Update Date:2023-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAMSW009568101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)