Provider Demographics
NPI:1598010480
Name:STUDLEY, ROBERT VINSON III (MA, LCPC)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:VINSON
Last Name:STUDLEY
Suffix:III
Gender:M
Credentials:MA, LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1669 WINDHAM WAY
Mailing Address - Street 2:
Mailing Address - City:O FALLON
Mailing Address - State:IL
Mailing Address - Zip Code:62269-3072
Mailing Address - Country:US
Mailing Address - Phone:618-622-2579
Mailing Address - Fax:618-624-8506
Practice Address - Street 1:1669 WINDHAM WAY
Practice Address - Street 2:
Practice Address - City:O FALLON
Practice Address - State:IL
Practice Address - Zip Code:62269-3072
Practice Address - Country:US
Practice Address - Phone:618-622-2579
Practice Address - Fax:618-624-8506
Is Sole Proprietor?:Yes
Enumeration Date:2012-07-17
Last Update Date:2022-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL237254917005Medicaid
IL237254917005Medicaid