Provider Demographics
NPI:1629439716
Name:PAESE, VIKKI
Entity Type:Individual
Prefix:
First Name:VIKKI
Middle Name:
Last Name:PAESE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:VIKKI
Other - Middle Name:JOY
Other - Last Name:CANNARELLA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2200 PRICE RD
Mailing Address - Street 2:
Mailing Address - City:MARTIN
Mailing Address - State:GA
Mailing Address - Zip Code:30557-3457
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2200 PRICE RD
Practice Address - Street 2:
Practice Address - City:MARTIN
Practice Address - State:GA
Practice Address - Zip Code:30557-3457
Practice Address - Country:US
Practice Address - Phone:706-779-5766
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-03-16
Last Update Date:2016-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAAPC004942101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional