Provider Demographics
NPI:1255829925
Name:VANCISE, EDWARD M (CDCA)
Entity Type:Individual
Prefix:
First Name:EDWARD
Middle Name:M
Last Name:VANCISE
Suffix:
Gender:M
Credentials:CDCA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2902 PENNY LN
Mailing Address - Street 2:
Mailing Address - City:AUSTINTOWN
Mailing Address - State:OH
Mailing Address - Zip Code:44515-4943
Mailing Address - Country:US
Mailing Address - Phone:330-564-3960
Mailing Address - Fax:
Practice Address - Street 1:2902 PENNY LANE
Practice Address - Street 2:
Practice Address - City:AUSTINTOWN
Practice Address - State:OH
Practice Address - Zip Code:44515
Practice Address - Country:US
Practice Address - Phone:330-564-3960
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-27
Last Update Date:2018-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHCDCA166799101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)