Provider Demographics
NPI:1366936239
Name:VAIL, DAVID R
Entity type:Individual
Prefix:
First Name:DAVID
Middle Name:R
Last Name:VAIL
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 1:8795 RIVER BIRCH RD
Mailing Address - Street 2:
Mailing Address - City:DAWSON
Mailing Address - State:IL
Mailing Address - Zip Code:62520-3350
Mailing Address - Country:US
Mailing Address - Phone:217-415-5005
Mailing Address - Fax:
Practice Address - Street 1:435 W WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:IL
Practice Address - Zip Code:62702-5006
Practice Address - Country:US
Practice Address - Phone:217-210-2476
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-06-14
Last Update Date:2018-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL149.020339101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor