Provider Demographics
NPI:1992923395
Name:PENNINGTON, YVONNE VICKERY
Entity type:Individual
Prefix:DR
First Name:YVONNE
Middle Name:VICKERY
Last Name:PENNINGTON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2760 TIMBERLINE RD NE
Mailing Address - Street 2:
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30062-1572
Mailing Address - Country:US
Mailing Address - Phone:404-255-6967
Mailing Address - Fax:404-843-8301
Practice Address - Street 1:300 WEST WIEUCA RD
Practice Address - Street 2:BLG 2 STE 314
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30312
Practice Address - Country:US
Practice Address - Phone:404-255-6967
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALPC875101Y00000X
GA2248103T00000X
GAMFT502106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered101Y00000XBehavioral Health & Social Service ProvidersCounselor
Not Answered103T00000XBehavioral Health & Social Service ProvidersPsychologist
Not Answered106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA0082242313Medicaid