Provider Demographics
NPI:1366235780
Name:STUBBLEFIELD, MASEY LODGE (EDS)
Entity type:Individual
Prefix:
First Name:MASEY
Middle Name:LODGE
Last Name:STUBBLEFIELD
Suffix:
Gender:F
Credentials:EDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:522 HAMILTON AVE
Mailing Address - Street 2:
Mailing Address - City:CHATTANOOGA
Mailing Address - State:TN
Mailing Address - Zip Code:37405-3937
Mailing Address - Country:US
Mailing Address - Phone:423-280-7761
Mailing Address - Fax:
Practice Address - Street 1:522 HAMILTON AVE
Practice Address - Street 2:
Practice Address - City:CHATTANOOGA
Practice Address - State:TN
Practice Address - Zip Code:37405-3937
Practice Address - Country:US
Practice Address - Phone:423-280-7761
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-05-28
Last Update Date:2025-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN000601749103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool