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General NPI Number Information
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NPI Number | 1518171222
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Entity Type | Organization
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Legal Business Name | GARY SANTAVICCA, PH.D. AND ASSOCIATES
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Dates
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Enumeration Date | 05/10/2007
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 340 BOULEVARD NE SUITE 640
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City | ATLANTA
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State | GA
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Zip | 30312-1273
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Country | US
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Telephone | 404-653-1117
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Fax | 404-880-0133
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Provider Business Mailing Address
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Address Line | 340 BOULEVARD NE SUITE 640
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City | ATLANTA
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State | GA
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Zip | 30312-1273
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Country | US
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Telephone | 404-653-1117
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Fax | 404-880-0133
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Authorized Official
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Title or Position | INSURANCE MANAGER
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Name | MS. AYANNA RULE
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Credential |
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Telephone | 404-653-1117
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103T00000X
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Taxonomy Name | Psychologist
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License Number | PSY001224
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License Number State | GA
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