MEDICARE: MS. GLENDA GAY VICK LMHC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YM0800X	Mental Health Counselor	MH3962	FL

General Provider Information

NPI Number	:	1164695177
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. GLENDA GAY VICK LMHC

Provider Business Mailing Address
First Line	:	407 N PARSONS AVE
Second Line	:	104A
City	:	BRANDON
State	:	FL
Zip	:	33510-4537
Country	:	US
Telephone Number	:	813-571-1684
Fax Number	:	813-657-5638

Provider Business Practice Location Address
First Line	:	407 N PARSONS AVE
Second Line	:	104A
City	:	BRANDON
State	:	FL
Zip	:	33510-4537
Country	:	US
Telephone Number	:	813-571-1684
Fax Number	:	813-657-5638

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/10/2008
Last Update Date	:	04/10/2008

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