Provider Demographics
NPI:1619607215
Name:REICH, VICKI RENEE
Entity Type:Individual
Prefix:
First Name:VICKI
Middle Name:RENEE
Last Name:REICH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4223 LILAC LN
Mailing Address - Street 2:
Mailing Address - City:MOUNT VERNON
Mailing Address - State:IL
Mailing Address - Zip Code:62864-2108
Mailing Address - Country:US
Mailing Address - Phone:618-214-5573
Mailing Address - Fax:
Practice Address - Street 1:4223 LILAC LN
Practice Address - Street 2:
Practice Address - City:MOUNT VERNON
Practice Address - State:IL
Practice Address - Zip Code:62864-2108
Practice Address - Country:US
Practice Address - Phone:618-214-5573
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-15
Last Update Date:2022-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL41171103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool