Healthcare Provider Details

I. General information

NPI: 1134825797
Provider Name (Legal Business Name): VICKY NGO LIEU
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/06/2023
Last Update Date: 09/24/2026
Certification Date: 09/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2100 CENTRAL AVE STE D1
AUGUSTA GA
30904-6709
US

IV. Provider business mailing address

2100 CENTRAL AVE STE D1
AUGUSTA GA
30904-6709
US

V. Phone/Fax

Practice location:
  • Phone: 706-843-6241
  • Fax: 706-843-6242
Mailing address:
  • Phone: 706-843-6241
  • Fax: 999-999-9999

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberAPC011311
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: