Provider Demographics
NPI:1275748725
Name:VINCENT, TROY LARRY SR (LAC)
Entity Type:Individual
Prefix:MR
First Name:TROY
Middle Name:LARRY
Last Name:VINCENT
Suffix:SR
Gender:M
Credentials:LAC
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 2306
Mailing Address - Street 2:
Mailing Address - City:STATE UNIVERSITY
Mailing Address - State:AR
Mailing Address - Zip Code:72467-2306
Mailing Address - Country:US
Mailing Address - Phone:870-258-8116
Mailing Address - Fax:
Practice Address - Street 1:1507 N. PECAN ST.
Practice Address - Street 2:
Practice Address - City:NEWPORT
Practice Address - State:AR
Practice Address - Zip Code:72112
Practice Address - Country:US
Practice Address - Phone:870-523-3643
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARA0704036101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health