Basic Information
| Provider Information | |||||||||
| NPI: | 1194893321 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | VICKERY | ||||||||
| FirstName: | GREGORY | ||||||||
| MiddleName: | ALAN | ||||||||
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| Credential: | LMFT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2178 JOHNSON AVE | ||||||||
| Address2: | |||||||||
| City: | SAN LUIS OBISPO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 934014535 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8054737142 | ||||||||
| FaxNumber: | 8054737124 | ||||||||
| Practice Location | |||||||||
| Address1: | 1092 E GRAND AVE | ||||||||
| Address2: | SUITE A | ||||||||
| City: | ARROYO GRANDE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 934202565 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8054737142 | ||||||||
| FaxNumber: | 8054737124 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/04/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106H00000X | MFC23249 | CA | Y | Behavioral Health & Social Service Providers | Marriage & Family Therapist |
No ID Information.