Provider Demographics
NPI:1134487564
Name:VANCE, MARCELINE (CCC-SLP)
Entity Type:Individual
Prefix:
First Name:MARCELINE
Middle Name:
Last Name:VANCE
Suffix:
Gender:F
Credentials:CCC-SLP
Other - Prefix:
Other - First Name:MARCY
Other - Middle Name:
Other - Last Name:VANCE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:3802 E NOWATA DR
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85044-2509
Mailing Address - Country:US
Mailing Address - Phone:480-242-5556
Mailing Address - Fax:
Practice Address - Street 1:3802 E NOWATA DR
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85044-2509
Practice Address - Country:US
Practice Address - Phone:480-242-5556
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-04-23
Last Update Date:2012-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA19360235Z00000X
AZSLP6767235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist