=====================================================
General NPI Number Information
=====================================================
NPI Number | 1336202795
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | VICKIE HARRISON LMSW
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/18/2006
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 18090 HIGHWAY 515 N P. O. 422
-----------------------------------------------------
City | ELLIJAY
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30536-1331
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 706-276-2024
-----------------------------------------------------
Fax | 706-276-1502
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1401 BURLEYSON DR
-----------------------------------------------------
City | DALTON
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30720-2522
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 706-270-5002
-----------------------------------------------------
Fax | 706-270-5111
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | MSW000155
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------