Provider Demographics
NPI:1598733099
Name:VANA, JUSTIN (PSYD)
Entity Type:Individual
Prefix:DR
First Name:JUSTIN
Middle Name:
Last Name:VANA
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:35 GROVE ST
Mailing Address - Street 2:APARTMENT B
Mailing Address - City:PAWTUCKET
Mailing Address - State:RI
Mailing Address - Zip Code:02860-3202
Mailing Address - Country:US
Mailing Address - Phone:913-424-3185
Mailing Address - Fax:
Practice Address - Street 1:830 CHALKSTONE AVE
Practice Address - Street 2:ROOM 368
Practice Address - City:PROVIDENCE
Practice Address - State:RI
Practice Address - Zip Code:02908-4734
Practice Address - Country:US
Practice Address - Phone:401-273-7100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-09
Last Update Date:2012-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOR0196103T00000X, 103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103T00000XBehavioral Health & Social Service ProvidersPsychologist