Provider Demographics
NPI:1932391984
Name:VICK, KENNETH JOHN (LCPC)
Entity Type:Individual
Prefix:MR
First Name:KENNETH
Middle Name:JOHN
Last Name:VICK
Suffix:
Gender:M
Credentials:LCPC
Other - Prefix:MR
Other - First Name:KEN
Other - Middle Name:J
Other - Last Name:VICK
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LCPC
Mailing Address - Street 1:10537 S ROBERTS RD
Mailing Address - Street 2:
Mailing Address - City:PALOS HILLS
Mailing Address - State:IL
Mailing Address - Zip Code:60465-1933
Mailing Address - Country:US
Mailing Address - Phone:708-974-2300
Mailing Address - Fax:
Practice Address - Street 1:10537 S ROBERTS RD
Practice Address - Street 2:
Practice Address - City:PALOS HILLS
Practice Address - State:IL
Practice Address - Zip Code:60465-1933
Practice Address - Country:US
Practice Address - Phone:708-974-2300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-08-14
Last Update Date:2014-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL180.003698101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional