Provider Demographics
NPI:1780716696
Name:GARRY VICKAR & ASSOCIATES
Entity type:Organization
Organization Name:GARRY VICKAR & ASSOCIATES
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:RITA
Authorized Official - Middle Name:W
Authorized Official - Last Name:HARRIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:314-837-4900
Mailing Address - Street 1:11125 DUNN RD
Mailing Address - Street 2:213
Mailing Address - City:ST LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63136
Mailing Address - Country:US
Mailing Address - Phone:314-837-4900
Mailing Address - Fax:314-837-5646
Practice Address - Street 1:11125 DUNN RD
Practice Address - Street 2:213
Practice Address - City:ST LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63136
Practice Address - Country:US
Practice Address - Phone:314-837-4900
Practice Address - Fax:314-837-5646
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-09
Last Update Date:2008-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL180000336103TC0700X
MO0031961041C0700X
MOR50512084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Multi-Specialty
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Multi-Specialty
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO502992407Medicaid
MO502992407Medicaid
A11033Medicare UPIN