Provider Demographics
NPI:1124525274
Name:VALLEJO DE PETER, GENELA GISSEL
Entity type:Individual
Prefix:
First Name:GENELA
Middle Name:GISSEL
Last Name:VALLEJO DE PETER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:GENELA
Other - Middle Name:GISSEL
Other - Last Name:VALLEJO DE PETER
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:140 ROSCOMMON CT
Mailing Address - Street 2:
Mailing Address - City:TYRONE
Mailing Address - State:GA
Mailing Address - Zip Code:30290-1879
Mailing Address - Country:US
Mailing Address - Phone:470-776-4223
Mailing Address - Fax:
Practice Address - Street 1:140 ROSCOMMON CT
Practice Address - Street 2:
Practice Address - City:TYRONE
Practice Address - State:GA
Practice Address - Zip Code:30290-1879
Practice Address - Country:US
Practice Address - Phone:470-776-4223
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-06
Last Update Date:2018-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician