Provider Demographics
NPI:1114134616
Name:VICKERY, PAULETTE (LCSW, LMFT)
Entity Type:Individual
Prefix:MRS
First Name:PAULETTE
Middle Name:
Last Name:VICKERY
Suffix:
Gender:F
Credentials:LCSW, LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1012 CHARLES ST
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40204-2406
Mailing Address - Country:US
Mailing Address - Phone:502-634-8435
Mailing Address - Fax:
Practice Address - Street 1:1012 CHARLES ST
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40204-2406
Practice Address - Country:US
Practice Address - Phone:502-634-8435
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-16
Last Update Date:2015-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY16461041C0700X
KY0561106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Not Answered106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CSW0272Medicare ID - Type Unspecified