1174008239 NPI number — MRS. SANDRA BERNADINE VANCE M.ED., LPC, NCC

Table of content: AMANDA IBRAHIM PHARMD (NPI 1134716756)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1174008239 NPI number — MRS. SANDRA BERNADINE VANCE M.ED., LPC, NCC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
VANCE
Provider First Name:
SANDRA
Provider Middle Name:
BERNADINE
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
M.ED., LPC, NCC
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1174008239
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/08/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
300 PROSPERITY LANE, SUITE #204
Provider Second Line Business Mailing Address:
PO BOX 176
Provider Business Mailing Address City Name:
LOGAN
Provider Business Mailing Address State Name:
WV
Provider Business Mailing Address Postal Code:
25601-3743
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
304-792-7130
Provider Business Mailing Address Fax Number:
304-896-5183

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
174 LMAMH CENTER ROAD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LOGAN
Provider Business Practice Location Address State Name:
WV
Provider Business Practice Location Address Postal Code:
25601-0176
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
304-792-7130
Provider Business Practice Location Address Fax Number:
304-792-7146
Provider Enumeration Date:
09/25/2018

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 101YP2500X , with the licence number:  2364 , registered in the state of WV ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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