Provider Demographics
NPI:1265470082
Name:BREWER CASPALL, VICKIE RENEA (PHD)
Entity Type:Individual
Prefix:DR
First Name:VICKIE
Middle Name:RENEA
Last Name:BREWER CASPALL
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:DR
Other - First Name:VICKIE
Other - Middle Name:RENEA
Other - Last Name:BREWER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PHD
Mailing Address - Street 1:PO BOX 814
Mailing Address - Street 2:
Mailing Address - City:WALNUT RIDGE
Mailing Address - State:AR
Mailing Address - Zip Code:72476-0814
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1045 W MAIN ST
Practice Address - Street 2:
Practice Address - City:WALNUT RIDGE
Practice Address - State:AR
Practice Address - Zip Code:72476-1004
Practice Address - Country:US
Practice Address - Phone:901-299-3836
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-03
Last Update Date:2018-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNP2103103G00000X, 174400000X
AR11-16P103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3583920Medicaid
TN3583920Medicaid