Provider Demographics
NPI:1902084650
Name:VICKERS, LISA A (LPC)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:A
Last Name:VICKERS
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3207 S CHEROKEE LN
Mailing Address - Street 2:SUITE 440
Mailing Address - City:WOODSTOCK
Mailing Address - State:GA
Mailing Address - Zip Code:30188-7024
Mailing Address - Country:US
Mailing Address - Phone:770-490-5501
Mailing Address - Fax:770-783-8380
Practice Address - Street 1:3207 S CHEROKEE LN
Practice Address - Street 2:SUITE 440
Practice Address - City:WOODSTOCK
Practice Address - State:GA
Practice Address - Zip Code:30188-7024
Practice Address - Country:US
Practice Address - Phone:770-490-5501
Practice Address - Fax:770-783-8380
Is Sole Proprietor?:No
Enumeration Date:2008-02-05
Last Update Date:2008-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALPC003790101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional