Basic Information
| Provider Information | |||||||||
| NPI: | 1336202795 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HARRISON | ||||||||
| FirstName: | VICKIE | ||||||||
| MiddleName: | |||||||||
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| Credential: | LMSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1401 BURLEYSON DR | ||||||||
| Address2: | |||||||||
| City: | DALTON | ||||||||
| State: | GA | ||||||||
| PostalCode: | 307202522 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7062705002 | ||||||||
| FaxNumber: | 7062705111 | ||||||||
| Practice Location | |||||||||
| Address1: | 18090 HIGHWAY 515 N | ||||||||
| Address2: | P. O. 422 | ||||||||
| City: | ELLIJAY | ||||||||
| State: | GA | ||||||||
| PostalCode: | 305361331 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7062762024 | ||||||||
| FaxNumber: | 7062761502 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/18/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | MSW000155 | GA | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.