Provider Demographics
NPI:1710386065
Name:VICK, LEIF (LPC)
Entity Type:Individual
Prefix:MR
First Name:LEIF
Middle Name:
Last Name:VICK
Suffix:
Gender:M
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:PO BOX 83046
Mailing Address - Street 2:
Mailing Address - City:FAIRBANKS
Mailing Address - State:AK
Mailing Address - Zip Code:99708-3046
Mailing Address - Country:US
Mailing Address - Phone:907-374-7776
Mailing Address - Fax:800-988-1650
Practice Address - Street 1:315 5TH AVE
Practice Address - Street 2:
Practice Address - City:FAIRBANKS
Practice Address - State:AK
Practice Address - Zip Code:99701-5025
Practice Address - Country:US
Practice Address - Phone:907-374-7776
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-08-21
Last Update Date:2014-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK883101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional