Provider Demographics
NPI:1174695019
Name:VICK, ANGELA GORDON (MED, CCC-SLP)
Entity type:Individual
Prefix:
First Name:ANGELA
Middle Name:GORDON
Last Name:VICK
Suffix:
Gender:F
Credentials:MED, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:244 LONG PINE DR
Mailing Address - Street 2:
Mailing Address - City:LEESBURG
Mailing Address - State:GA
Mailing Address - Zip Code:31763-3175
Mailing Address - Country:US
Mailing Address - Phone:229-395-9255
Mailing Address - Fax:
Practice Address - Street 1:244 LONG PINE DR
Practice Address - Street 2:
Practice Address - City:LEESBURG
Practice Address - State:GA
Practice Address - Zip Code:31763-3175
Practice Address - Country:US
Practice Address - Phone:229-395-9255
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GASLP004869235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist