Provider Demographics
NPI:1114245602
Name:VANCE, ROBERT JAY (MS, LPC, NCC)
Entity Type:Individual
Prefix:MR
First Name:ROBERT
Middle Name:JAY
Last Name:VANCE
Suffix:
Gender:M
Credentials:MS, LPC, NCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PSC 817 BOX 14
Mailing Address - Street 2:
Mailing Address - City:FPO
Mailing Address - State:AE
Mailing Address - Zip Code:09622-0014
Mailing Address - Country:US
Mailing Address - Phone:0113-908-1568
Mailing Address - Fax:081-568-5299
Practice Address - Street 1:PSC 817 BOX 14
Practice Address - Street 2:
Practice Address - City:FPO
Practice Address - State:AE
Practice Address - Zip Code:09622-0014
Practice Address - Country:US
Practice Address - Phone:0113-908-1568
Practice Address - Fax:081-568-5299
Is Sole Proprietor?:Yes
Enumeration Date:2010-05-10
Last Update Date:2010-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC3281101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional