Provider Demographics
NPI:1306974613
Name:VICK, BLAIR WILLIS (MS, CCC-SLP)
Entity type:Individual
Prefix:MRS
First Name:BLAIR
Middle Name:WILLIS
Last Name:VICK
Suffix:
Gender:F
Credentials:MS, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:115 REGENCY BLVD
Mailing Address - Street 2:B
Mailing Address - City:GREENVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:27834-4645
Mailing Address - Country:US
Mailing Address - Phone:252-756-3099
Mailing Address - Fax:252-756-0667
Practice Address - Street 1:115 REGENCY BLVD
Practice Address - Street 2:B
Practice Address - City:GREENVILLE
Practice Address - State:NC
Practice Address - Zip Code:27834-4645
Practice Address - Country:US
Practice Address - Phone:252-756-3099
Practice Address - Fax:252-756-0667
Is Sole Proprietor?:No
Enumeration Date:2007-02-28
Last Update Date:2010-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC5713235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7411949Medicaid