Provider Demographics
NPI:1346653896
Name:VANCE, KYLEE R (LAC, LPCC)
Entity Type:Individual
Prefix:
First Name:KYLEE
Middle Name:R
Last Name:VANCE
Suffix:
Gender:F
Credentials:LAC, LPCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3407 BAY SHORE BND SE
Mailing Address - Street 2:
Mailing Address - City:MANDAN
Mailing Address - State:ND
Mailing Address - Zip Code:58554-6260
Mailing Address - Country:US
Mailing Address - Phone:701-220-9547
Mailing Address - Fax:
Practice Address - Street 1:1120 COLLEGE DR STE 201
Practice Address - Street 2:
Practice Address - City:BISMARCK
Practice Address - State:ND
Practice Address - Zip Code:58501-1225
Practice Address - Country:US
Practice Address - Phone:701-258-2008
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-06-03
Last Update Date:2020-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND1704101YA0400X
ND937-2-1-18101YP2500X
ND425810101YS0200X
ND937-2-1-18-404101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YS0200XBehavioral Health & Social Service ProvidersCounselorSchool