Provider Demographics
NPI:1790373074
Name:VANCE, REBECCA SUE (BSW, LSW)
Entity Type:Individual
Prefix:
First Name:REBECCA
Middle Name:SUE
Last Name:VANCE
Suffix:
Gender:F
Credentials:BSW, LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 835
Mailing Address - Street 2:
Mailing Address - City:MULLENS
Mailing Address - State:WV
Mailing Address - Zip Code:25882-0835
Mailing Address - Country:US
Mailing Address - Phone:304-294-5610
Mailing Address - Fax:304-294-2040
Practice Address - Street 1:3776 MOUNTAINEER HIGHWAY
Practice Address - Street 2:
Practice Address - City:MABEN
Practice Address - State:WV
Practice Address - Zip Code:25870
Practice Address - Country:US
Practice Address - Phone:304-294-5610
Practice Address - Fax:304-294-2040
Is Sole Proprietor?:No
Enumeration Date:2021-01-04
Last Update Date:2021-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVAP00941743104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker