Provider Demographics
NPI:1083638506
Name:VICKERY, ROBIN DENISE (LPC)
Entity type:Individual
Prefix:MISS
First Name:ROBIN
Middle Name:DENISE
Last Name:VICKERY
Suffix:
Gender:F
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 280
Mailing Address - Street 2:
Mailing Address - City:POPLAR BLUFF
Mailing Address - State:MO
Mailing Address - Zip Code:63902-0280
Mailing Address - Country:US
Mailing Address - Phone:573-686-1200
Mailing Address - Fax:573-686-1029
Practice Address - Street 1:3001 WARRIOR LN
Practice Address - Street 2:
Practice Address - City:POPLAR BLUFF
Practice Address - State:MO
Practice Address - Zip Code:63901-8685
Practice Address - Country:US
Practice Address - Phone:573-686-1200
Practice Address - Fax:573-686-1029
Is Sole Proprietor?:No
Enumeration Date:2006-07-27
Last Update Date:2009-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2001020523101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
431116734OtherEAP INTERFACE
763085OtherHEALTHLINK HMO
11621287OtherCAQH
9875OtherEAP FEI BEHAVIORAL HEALTH
152958OtherBLUE CROSS BLUE SHIELD
MO495346504Medicaid
431116734OtherVALUE OPTIONS