Provider Demographics
NPI:1558470419
Name:SOUTHPARK PSYCHOLOGY LTD
Entity Type:Organization
Organization Name:SOUTHPARK PSYCHOLOGY LTD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:CARL
Authorized Official - Middle Name:
Authorized Official - Last Name:VINCENT
Authorized Official - Suffix:
Authorized Official - Credentials:LCPC
Authorized Official - Phone:309-797-2900
Mailing Address - Street 1:2100 52ND AVE
Mailing Address - Street 2:
Mailing Address - City:MOLINE
Mailing Address - State:IL
Mailing Address - Zip Code:61265-6366
Mailing Address - Country:US
Mailing Address - Phone:309-797-2900
Mailing Address - Fax:309-797-2147
Practice Address - Street 1:2100 52ND AVE
Practice Address - Street 2:
Practice Address - City:MOLINE
Practice Address - State:IL
Practice Address - Zip Code:61265-6366
Practice Address - Country:US
Practice Address - Phone:309-797-2900
Practice Address - Fax:309-797-2147
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-30
Last Update Date:2018-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounselingGroup - Multi-Specialty
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Multi-Specialty
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty