Provider Demographics
NPI:1861684789
Name:VICKERY, ROBIN KAY (LCSW)
Entity Type:Individual
Prefix:
First Name:ROBIN
Middle Name:KAY
Last Name:VICKERY
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:497 SW CENTURY DR STE 102
Mailing Address - Street 2:
Mailing Address - City:BEND
Mailing Address - State:OR
Mailing Address - Zip Code:97702-1167
Mailing Address - Country:US
Mailing Address - Phone:541-640-2101
Mailing Address - Fax:541-797-6898
Practice Address - Street 1:497 SW CENTURY DR STE 102
Practice Address - Street 2:
Practice Address - City:BEND
Practice Address - State:OR
Practice Address - Zip Code:97702-1167
Practice Address - Country:US
Practice Address - Phone:541-640-2101
Practice Address - Fax:541-797-6898
Is Sole Proprietor?:No
Enumeration Date:2007-08-14
Last Update Date:2020-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORL35471041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500635975Medicaid
ORR159008Medicare PIN