Provider Demographics
NPI:1891364592
Name:VANCE, CARLTON ALAN
Entity Type:Individual
Prefix:
First Name:CARLTON
Middle Name:ALAN
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 1:1116 CREST BREEZE DR
Mailing Address - Street 2:
Mailing Address - City:HASLET
Mailing Address - State:TX
Mailing Address - Zip Code:76052-6149
Mailing Address - Country:US
Mailing Address - Phone:817-715-9869
Mailing Address - Fax:
Practice Address - Street 1:1116 CREST BREEZE DR
Practice Address - Street 2:
Practice Address - City:HASLET
Practice Address - State:TX
Practice Address - Zip Code:76052-6149
Practice Address - Country:US
Practice Address - Phone:817-715-9869
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-18
Last Update Date:2021-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX83298101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional