Healthcare Provider Details

I. General information

NPI: 1730394073
Provider Name (Legal Business Name): STEPHEN G. VINCENT PH.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/11/2007
Last Update Date: 09/11/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

450 S DURKIN DR STE. C
SPRINGFIELD IL
62704-7212
US

IV. Provider business mailing address

450 S DURKIN DR STE. C
SPRINGFIELD IL
62704-7212
US

V. Phone/Fax

Practice location:
  • Phone: 217-793-1567
  • Fax: 217-793-1930
Mailing address:
  • Phone: 217-793-1567
  • Fax: 217-793-1930

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number71-3280
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number1999140679
License Number StateMO
# 3
Primary TaxonomyN
Taxonomy Code103TC2200X
TaxonomyClinical Child & Adolescent Psychologist
License Number71-3280
License Number StateIL
# 4
Primary TaxonomyN
Taxonomy Code103TR0400X
TaxonomyRehabilitation Psychologist
License Number71-3280
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: