Provider Demographics
NPI:1053063370
Name:VANCE, THEODORA RENAE (LCSW)
Entity Type:Individual
Prefix:MS
First Name:THEODORA
Middle Name:RENAE
Last Name:VANCE
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:51 DA BOYZ PL
Mailing Address - Street 2:
Mailing Address - City:AFTON
Mailing Address - State:VA
Mailing Address - Zip Code:22920-3063
Mailing Address - Country:US
Mailing Address - Phone:434-466-8700
Mailing Address - Fax:
Practice Address - Street 1:51 DA BOYZ PL
Practice Address - Street 2:
Practice Address - City:AFTON
Practice Address - State:VA
Practice Address - Zip Code:22920-3063
Practice Address - Country:US
Practice Address - Phone:434-466-8700
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-01-19
Last Update Date:2022-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA09040091151041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical