Provider Demographics
NPI:1326352287
Name:VANCE, RUSSELL EDWARD III (PHD)
Entity Type:Individual
Prefix:DR
First Name:RUSSELL
Middle Name:EDWARD
Last Name:VANCE
Suffix:III
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8000 LAUDERDALE DR
Mailing Address - Street 2:
Mailing Address - City:EVANSVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:47715-6238
Mailing Address - Country:US
Mailing Address - Phone:812-550-0127
Mailing Address - Fax:
Practice Address - Street 1:8000 LAUDERDALE DR
Practice Address - Street 2:
Practice Address - City:EVANSVILLE
Practice Address - State:IN
Practice Address - Zip Code:47715-6238
Practice Address - Country:US
Practice Address - Phone:812-550-0127
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-08-03
Last Update Date:2010-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN39000214A101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor