Provider Demographics
NPI:1821649229
Name:VANCE, PADEN
Entity Type:Individual
Prefix:
First Name:PADEN
Middle Name:
Last Name:VANCE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12849 N FARLEY WAY
Mailing Address - Street 2:
Mailing Address - City:RATHDRUM
Mailing Address - State:ID
Mailing Address - Zip Code:83858-0940
Mailing Address - Country:US
Mailing Address - Phone:509-863-7567
Mailing Address - Fax:
Practice Address - Street 1:784 S CLEARWATER LOOP STE B
Practice Address - Street 2:
Practice Address - City:POST FALLS
Practice Address - State:ID
Practice Address - Zip Code:83854-9599
Practice Address - Country:US
Practice Address - Phone:208-505-8155
Practice Address - Fax:208-416-6663
Is Sole Proprietor?:No
Enumeration Date:2019-09-26
Last Update Date:2024-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLCPC-10266101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional