Provider Demographics
NPI:1689660235
Name:LEOPOLD, VICKI M (LCSW)
Entity Type:Individual
Prefix:MRS
First Name:VICKI
Middle Name:M
Last Name:LEOPOLD
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:VICKI
Other - Middle Name:M
Other - Last Name:STROM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:170 BROADMOOR DR
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30215-2714
Mailing Address - Country:US
Mailing Address - Phone:770-461-0284
Mailing Address - Fax:770-461-0284
Practice Address - Street 1:170 BROADMOOR DR
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30215-2714
Practice Address - Country:US
Practice Address - Phone:770-461-0284
Practice Address - Fax:770-461-0284
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACSW0033851041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA654749047AMedicaid