Provider Demographics
NPI:1578921508
Name:SCIVICQUE, LILY (LPC)
Entity Type:Individual
Prefix:
First Name:LILY
Middle Name:
Last Name:SCIVICQUE
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1032 LENA ST NW
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30314-2953
Mailing Address - Country:US
Mailing Address - Phone:404-790-0800
Mailing Address - Fax:
Practice Address - Street 1:80 JESSE HILL JR DR SE
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30303-3031
Practice Address - Country:US
Practice Address - Phone:404-790-0800
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-02-04
Last Update Date:2016-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALPC008657101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional