Provider Demographics
NPI:1174008239
Name:VANCE, SANDRA BERNADINE (MED, LPC, NCC)
Entity Type:Individual
Prefix:MRS
First Name:SANDRA
Middle Name:BERNADINE
Last Name:VANCE
Suffix:
Gender:F
Credentials:MED, LPC, NCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 PROSPERITY LANE, SUITE #204
Mailing Address - Street 2:PO BOX 176
Mailing Address - City:LOGAN
Mailing Address - State:WV
Mailing Address - Zip Code:25601-3743
Mailing Address - Country:US
Mailing Address - Phone:304-792-7130
Mailing Address - Fax:304-896-5183
Practice Address - Street 1:174 LMAMH CENTER ROAD
Practice Address - Street 2:
Practice Address - City:LOGAN
Practice Address - State:WV
Practice Address - Zip Code:25601-0176
Practice Address - Country:US
Practice Address - Phone:304-792-7130
Practice Address - Fax:304-792-7146
Is Sole Proprietor?:Yes
Enumeration Date:2018-09-25
Last Update Date:2019-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV2364101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional