Provider Demographics
NPI:1497821672
Name:RIVER, VINCENT BRYAN (PHD)
Entity Type:Individual
Prefix:DR
First Name:VINCENT
Middle Name:BRYAN
Last Name:RIVER
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1201 MAIN ST
Mailing Address - Street 2:SUITE A
Mailing Address - City:POLSON
Mailing Address - State:MT
Mailing Address - Zip Code:59860-5333
Mailing Address - Country:US
Mailing Address - Phone:406-883-8126
Mailing Address - Fax:406-883-9226
Practice Address - Street 1:1201 MAIN ST
Practice Address - Street 2:SUITE A
Practice Address - City:POLSON
Practice Address - State:MT
Practice Address - Zip Code:59860-5333
Practice Address - Country:US
Practice Address - Phone:406-883-8126
Practice Address - Fax:406-883-9226
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-28
Last Update Date:2012-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT328103TC2200X, 103TF0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent
No103TF0200XBehavioral Health & Social Service ProvidersPsychologistForensic
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT490739Medicaid
MT51871OtherBLUE CROSS BLUE SHIELD
MT7718 59860 0000OtherTRICARE
MT7718 59860 0000OtherTRICARE
MT490739Medicaid
MT50253Medicare PIN