Provider Demographics
NPI:1700223831
Name:VICKREY, ROBERT H (MA, LCAC)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:H
Last Name:VICKREY
Suffix:
Gender:M
Credentials:MA, LCAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:850 N HARRISON ST
Mailing Address - Street 2:
Mailing Address - City:WARSAW
Mailing Address - State:IN
Mailing Address - Zip Code:46580-3163
Mailing Address - Country:US
Mailing Address - Phone:574-267-7169
Mailing Address - Fax:574-269-5573
Practice Address - Street 1:101 E PARK DR
Practice Address - Street 2:
Practice Address - City:ALBION
Practice Address - State:IN
Practice Address - Zip Code:46701-1438
Practice Address - Country:US
Practice Address - Phone:260-636-6884
Practice Address - Fax:260-636-3392
Is Sole Proprietor?:No
Enumeration Date:2013-05-30
Last Update Date:2013-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN87001430A101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)