MEDICARE: DEANA JO VIVIAN

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	101YP2500X	Professional Counselor	LPC009559	GA

General Provider Information

NPI Number	:	1639695513
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DEANA JO VIVIAN

Provider Business Mailing Address
First Line	:	1003 VIRGINIA AVE STE 212
Second Line	:
City	:	ATLANTA
State	:	GA
Zip	:	30354-1387
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1003 VIRGINIA AVE STE 212
Second Line	:
City	:	ATLANTA
State	:	GA
Zip	:	30354-1387
Country	:	US
Telephone Number	:	678-994-5694
Fax Number	:

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

Provider Enumeration Date	:	08/22/2017
Last Update Date	:	08/22/2017

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