Provider Demographics
NPI:1114476884
Name:VANN, BOBBY JR (LGPC)
Entity Type:Individual
Prefix:MR
First Name:BOBBY
Middle Name:
Last Name:VANN
Suffix:JR
Gender:M
Credentials:LGPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8415 BELLONA LN
Mailing Address - Street 2:SUITE 215
Mailing Address - City:TOWSON
Mailing Address - State:MD
Mailing Address - Zip Code:21204-2055
Mailing Address - Country:US
Mailing Address - Phone:410-245-2611
Mailing Address - Fax:
Practice Address - Street 1:8415 BELLONA LN
Practice Address - Street 2:SUITE 215
Practice Address - City:TOWSON
Practice Address - State:MD
Practice Address - Zip Code:21204-2055
Practice Address - Country:US
Practice Address - Phone:410-245-2611
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-09-23
Last Update Date:2016-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDLGP7337101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health