Provider Demographics
NPI:1841042520
Name:VICK, JAMES ANTHONY
Entity type:Individual
Prefix:
First Name:JAMES
Middle Name:ANTHONY
Last Name:VICK
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11136 SUNBURST LN APT F
Mailing Address - Street 2:
Mailing Address - City:FREDERICKSBURG
Mailing Address - State:VA
Mailing Address - Zip Code:22407-7647
Mailing Address - Country:US
Mailing Address - Phone:704-221-8524
Mailing Address - Fax:
Practice Address - Street 1:11136 SUNBURST LN APT F
Practice Address - Street 2:
Practice Address - City:FREDERICKSBURG
Practice Address - State:VA
Practice Address - Zip Code:22407-7647
Practice Address - Country:US
Practice Address - Phone:704-221-8524
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-04-04
Last Update Date:2024-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Single Specialty