Provider Demographics
NPI:1366579062
Name:VESCOVO, MERRIDY K (LPC LMFT)
Entity type:Individual
Prefix:MRS
First Name:MERRIDY
Middle Name:K
Last Name:VESCOVO
Suffix:
Gender:F
Credentials:LPC LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1000 MAIN STREET
Mailing Address - Street 2:SUITE A
Mailing Address - City:STONE MOUNTAIN
Mailing Address - State:GA
Mailing Address - Zip Code:30083
Mailing Address - Country:US
Mailing Address - Phone:770-498-6300
Mailing Address - Fax:770-498-4999
Practice Address - Street 1:1000 MAIN STREET
Practice Address - Street 2:SUITE A
Practice Address - City:STONE MOUNTAIN
Practice Address - State:GA
Practice Address - Zip Code:30083
Practice Address - Country:US
Practice Address - Phone:770-498-6300
Practice Address - Fax:770-498-4999
Is Sole Proprietor?:No
Enumeration Date:2007-02-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA2378LPC101YM0800X
GALMFT 867106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Not Answered106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist