Provider Demographics
NPI:1265581987
Name:VICKERY, CHAD (PHD)
Entity type:Individual
Prefix:
First Name:CHAD
Middle Name:
Last Name:VICKERY
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 1:480 MEDICAL CENTER DR
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43210-1229
Mailing Address - Country:US
Mailing Address - Phone:614-293-3830
Mailing Address - Fax:614-293-4870
Practice Address - Street 1:480 MEDICAL CENTER DR
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43210-1229
Practice Address - Country:US
Practice Address - Phone:614-293-3830
Practice Address - Fax:614-293-4870
Is Sole Proprietor?:No
Enumeration Date:2007-01-10
Last Update Date:2011-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH6807103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS05800054Medicaid
MS680000256Medicare ID - Type UnspecifiedPROVIDER NUMBER
MS05800054Medicaid