MEDICARE: DR. BARRY ALAN VINICK PHD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103T00000X	Psychologist	P1341	TN
2	103T00000X	Psychologist	30452	MS

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1801853536
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. BARRY ALAN VINICK PHD

Provider Business Mailing Address
First Line	:	PO BOX 269
Second Line	:
City	:	ELLENDALE
State	:	TN
Zip	:	38029-0269
Country	:	US
Telephone Number	:	662-342-2733
Fax Number	:	662-342-5993

Provider Business Practice Location Address
First Line	:	6911 PARKWOOD DR
Second Line	:
City	:	OLIVE BRANCH
State	:	MS
Zip	:	38654-2111
Country	:	US
Telephone Number	:	662-342-2733
Fax Number	:	662-342-5993

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/27/2006
Last Update Date	:	02/22/2026

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