Provider Demographics
NPI:1386711067
Name:VICKERS, STACEE (PT)
Entity type:Individual
Prefix:MRS
First Name:STACEE
Middle Name:
Last Name:VICKERS
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1092 ADAH LN
Mailing Address - Street 2:
Mailing Address - City:LAWRENCEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30043-7225
Mailing Address - Country:US
Mailing Address - Phone:678-618-9022
Mailing Address - Fax:
Practice Address - Street 1:318 W PIKE ST
Practice Address - Street 2:SUITE 104
Practice Address - City:LAWRENCEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30045-3234
Practice Address - Country:US
Practice Address - Phone:678-377-2833
Practice Address - Fax:678-377-2882
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-29
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA0048172251P0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251P0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA307933OtherWELLCARE PROVIDER #
GA00776993DMedicaid
GA10037646OtherAMERIGROUP PROVIDER #