Provider Demographics
NPI:1518171222
Name:GARY SANTAVICCA, PH.D. AND ASSOCIATES
Entity Type:Organization
Organization Name:GARY SANTAVICCA, PH.D. AND ASSOCIATES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:INSURANCE MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:AYANNA
Authorized Official - Middle Name:
Authorized Official - Last Name:RULE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:404-653-1117
Mailing Address - Street 1:340 BOULEVARD NE
Mailing Address - Street 2:SUITE 640
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30312-1273
Mailing Address - Country:US
Mailing Address - Phone:404-653-1117
Mailing Address - Fax:404-880-0133
Practice Address - Street 1:340 BOULEVARD NE
Practice Address - Street 2:SUITE 640
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30312-1273
Practice Address - Country:US
Practice Address - Phone:404-653-1117
Practice Address - Fax:404-880-0133
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-10
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPSY001224103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00423178BMedicaid
GA00423178AMedicaid
GA00423178BMedicaid
GAR12549Medicare UPIN