Provider Demographics
NPI:1730394073
Name:VINCENT, STEPHEN G (PHD)
Entity type:Individual
Prefix:DR
First Name:STEPHEN
Middle Name:G
Last Name:VINCENT
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 1:450 S DURKIN DR
Mailing Address - Street 2:STE. C
Mailing Address - City:SPRINGFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:62704-7212
Mailing Address - Country:US
Mailing Address - Phone:217-793-1567
Mailing Address - Fax:217-793-1930
Practice Address - Street 1:450 S DURKIN DR
Practice Address - Street 2:STE. C
Practice Address - City:SPRINGFIELD
Practice Address - State:IL
Practice Address - Zip Code:62704-7212
Practice Address - Country:US
Practice Address - Phone:217-793-1567
Practice Address - Fax:217-793-1930
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL71-3280103TC2200X, 103TR0400X, 103TC0700X
MO1999140679103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent
Not Answered103TR0400XBehavioral Health & Social Service ProvidersPsychologistRehabilitation
Not Answered103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical