Provider Demographics
NPI:1275598138
Name:VALLANCE, ILENE MARIE (LMSW)
Entity Type:Individual
Prefix:
First Name:ILENE
Middle Name:MARIE
Last Name:VALLANCE
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:ILENE
Other - Middle Name:MARIE
Other - Last Name:JOLLY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LMSW
Mailing Address - Street 1:3333 MOORES RIVER DR UNIT 208
Mailing Address - Street 2:
Mailing Address - City:LANSING
Mailing Address - State:MI
Mailing Address - Zip Code:48911-1054
Mailing Address - Country:US
Mailing Address - Phone:517-614-3903
Mailing Address - Fax:
Practice Address - Street 1:3333 MOORES RIVER DR UNIT 208
Practice Address - Street 2:
Practice Address - City:LANSING
Practice Address - State:MI
Practice Address - Zip Code:48911-1054
Practice Address - Country:US
Practice Address - Phone:517-614-3903
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-04-20
Last Update Date:2023-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010781511041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0C36171105Medicare ID - Type UnspecifiedMEDICARE