Provider Demographics
NPI:1396772232
Name:VINCENT, WESLEY L (PHD)
Entity type:Individual
Prefix:
First Name:WESLEY
Middle Name:L
Last Name:VINCENT
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:WESLEY
Other - Middle Name:L
Other - Last Name:VINCENT
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PHD
Mailing Address - Street 1:206 BOSTON TPKE
Mailing Address - Street 2:
Mailing Address - City:POMFRET CENTER
Mailing Address - State:CT
Mailing Address - Zip Code:06259-9514
Mailing Address - Country:US
Mailing Address - Phone:860-974-2994
Mailing Address - Fax:860-974-2994
Practice Address - Street 1:139 HAZARD AVE
Practice Address - Street 2:SUITE 7
Practice Address - City:ENFIELD
Practice Address - State:CT
Practice Address - Zip Code:06082-4597
Practice Address - Country:US
Practice Address - Phone:860-763-4465
Practice Address - Fax:860-763-4467
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-27
Last Update Date:2012-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT001556103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT004134459Medicaid
680000468Medicare ID - Type Unspecified