Provider Demographics
NPI:1124080395
Name:SANTAVICCA, GARY (PHD)
Entity type:Individual
Prefix:
First Name:GARY
Middle Name:
Last Name:SANTAVICCA
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:340 BLVD NE
Mailing Address - Street 2:STE 640
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30312
Mailing Address - Country:US
Mailing Address - Phone:404-653-1117
Mailing Address - Fax:404-880-0133
Practice Address - Street 1:340 BLVD NE
Practice Address - Street 2:STE 640
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30312
Practice Address - Country:US
Practice Address - Phone:404-653-1117
Practice Address - Fax:404-880-0133
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-04-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA1224103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00423178AMedicaid
R12549Medicare UPIN
GA00423178AMedicaid