Provider Demographics
NPI:1902349186
Name:BURRELL, VIVIAN (LCSW)
Entity Type:Individual
Prefix:
First Name:VIVIAN
Middle Name:
Last Name:BURRELL
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3540 SENTRY VIEW TRCE
Mailing Address - Street 2:
Mailing Address - City:SUWANEE
Mailing Address - State:GA
Mailing Address - Zip Code:30024-7493
Mailing Address - Country:US
Mailing Address - Phone:770-625-0220
Mailing Address - Fax:
Practice Address - Street 1:2180 SATELLITE BLVD
Practice Address - Street 2:
Practice Address - City:DULUTH
Practice Address - State:GA
Practice Address - Zip Code:30097-4028
Practice Address - Country:US
Practice Address - Phone:770-625-0220
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-11-21
Last Update Date:2016-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACSW0048711041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical