Basic Information
| Provider Information | |||||||||
| NPI: | 1255373841 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | VICKERY | ||||||||
| FirstName: | DONNA | ||||||||
| MiddleName: | R | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 19 PROSPECT ST | ||||||||
| Address2: | |||||||||
| City: | SUMMIT | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 079012530 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3307584515 | ||||||||
| FaxNumber: | 3307585121 | ||||||||
| Practice Location | |||||||||
| Address1: | 19 PROSPECT ST | ||||||||
| Address2: | |||||||||
| City: | SUMMIT | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 079012530 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3307584515 | ||||||||
| FaxNumber: | 3307585121 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/11/2006 | ||||||||
| LastUpdateDate: | 03/31/2009 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103T00000X | 25MA05262400 | NJ | Y | Behavioral Health & Social Service Providers | Psychologist |
No ID Information.