Healthcare Provider Details

I. General information

NPI: 1558470419
Provider Name (Legal Business Name): SOUTHPARK PSYCHOLOGY LTD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/30/2006
Last Update Date: 01/26/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2100 52ND AVE
MOLINE IL
61265-6366
US

IV. Provider business mailing address

2100 52ND AVE
MOLINE IL
61265-6366
US

V. Phone/Fax

Practice location:
  • Phone: 309-797-2900
  • Fax: 309-797-2147
Mailing address:
  • Phone: 309-797-2900
  • Fax: 309-797-2147

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State

VIII. Authorized Official

Name: DR. CARL VINCENT
Title or Position: OWNER
Credential: LCPC
Phone: 309-797-2900