Provider Demographics
NPI:1174689731
Name:GRIECO, VINCENT (PHD)
Entity Type:Individual
Prefix:DR
First Name:VINCENT
Middle Name:
Last Name:GRIECO
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:DR
Other - First Name:VINCENT
Other - Middle Name:
Other - Last Name:GRIECO
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PHD
Mailing Address - Street 1:315 W PONCE DE LEON AVE
Mailing Address - Street 2:SUITE 922
Mailing Address - City:DECATUR
Mailing Address - State:GA
Mailing Address - Zip Code:30030-2400
Mailing Address - Country:US
Mailing Address - Phone:404-373-8154
Mailing Address - Fax:404-373-8141
Practice Address - Street 1:315 W PONCE DE LEON AVE
Practice Address - Street 2:SUITE922
Practice Address - City:DECATUR
Practice Address - State:GA
Practice Address - Zip Code:30030-2400
Practice Address - Country:US
Practice Address - Phone:404-373-8154
Practice Address - Fax:404-373-8141
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-28
Last Update Date:2008-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA2366103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00867171AMedicaid
GA68BBFSZMedicare PIN