Provider Demographics
NPI:1447592209
Name:VINSON PSYCHOLOGICAL SERVICES, PLLC
Entity type:Organization
Organization Name:VINSON PSYCHOLOGICAL SERVICES, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL PSYCHOLOGIST
Authorized Official - Prefix:
Authorized Official - First Name:MARTHA
Authorized Official - Middle Name:ANNE
Authorized Official - Last Name:VINSON
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:336-972-1164
Mailing Address - Street 1:4236 SHERLIE WEAVIL RD
Mailing Address - Street 2:
Mailing Address - City:WINSTON-SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27107
Mailing Address - Country:US
Mailing Address - Phone:336-972-1164
Mailing Address - Fax:
Practice Address - Street 1:4236 SHERLIE WEAVIL RD
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27107
Practice Address - Country:US
Practice Address - Phone:336-972-1164
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-03-20
Last Update Date:2013-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC1596103TR0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TR0400XBehavioral Health & Social Service ProvidersPsychologistRehabilitationGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6006146Medicaid
NC235045WMedicare PIN