Provider Demographics
NPI:1801853536
Name:VINICK, BARRY ALAN (PHD)
Entity Type:Individual
Prefix:DR
First Name:BARRY
Middle Name:ALAN
Last Name:VINICK
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:PO BOX 269
Mailing Address - Street 2:
Mailing Address - City:ELLENDALE
Mailing Address - State:TN
Mailing Address - Zip Code:38029-0269
Mailing Address - Country:US
Mailing Address - Phone:662-342-2733
Mailing Address - Fax:662-342-5993
Practice Address - Street 1:6911 PARKWOOD DR
Practice Address - Street 2:
Practice Address - City:OLIVE BRANCH
Practice Address - State:MS
Practice Address - Zip Code:38654-2111
Practice Address - Country:US
Practice Address - Phone:662-342-2733
Practice Address - Fax:662-342-5993
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-27
Last Update Date:2020-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNP1341103T00000X
MS30452103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS0018297Medicaid
TN3682379Medicaid
MS0018297Medicaid