Provider Demographics
NPI:1407165798
Name:VICK, RONALD DEAN JR
Entity Type:Individual
Prefix:MR
First Name:RONALD
Middle Name:DEAN
Last Name:VICK
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2501 LAKERIDGE DR
Mailing Address - Street 2:STE. 104C
Mailing Address - City:NORFOLK
Mailing Address - State:NE
Mailing Address - Zip Code:68701-2558
Mailing Address - Country:US
Mailing Address - Phone:402-640-5569
Mailing Address - Fax:402-844-3406
Practice Address - Street 1:2501 LAKERIDGE DR
Practice Address - Street 2:STE. 104C
Practice Address - City:NORFOLK
Practice Address - State:NE
Practice Address - Zip Code:68701-2558
Practice Address - Country:US
Practice Address - Phone:402-640-5569
Practice Address - Fax:402-844-3406
Is Sole Proprietor?:No
Enumeration Date:2010-10-04
Last Update Date:2012-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171M00000X
NE9588101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No171M00000XOther Service ProvidersCase Manager/Care Coordinator