Provider Demographics
NPI:1922019991
Name:VINCENT, CARL D
Entity Type:Individual
Prefix:
First Name:CARL
Middle Name:D
Last Name:VINCENT
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2100 52ND AVE
Mailing Address - Street 2:
Mailing Address - City:MOLINE
Mailing Address - State:IL
Mailing Address - Zip Code:61265-6366
Mailing Address - Country:US
Mailing Address - Phone:309-797-2900
Mailing Address - Fax:309-797-2147
Practice Address - Street 1:2100 52ND AVE
Practice Address - Street 2:
Practice Address - City:MOLINE
Practice Address - State:IL
Practice Address - Zip Code:61265-6366
Practice Address - Country:US
Practice Address - Phone:309-797-2900
Practice Address - Fax:309-797-2147
Is Sole Proprietor?:No
Enumeration Date:2006-08-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILL78997Medicare UPIN