Provider Demographics
NPI:1932673142
Name:KORANTENG ADANSI, VIDA (LCP)
Entity Type:Individual
Prefix:
First Name:VIDA
Middle Name:
Last Name:KORANTENG ADANSI
Suffix:
Gender:F
Credentials:LCP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1275B W PULASKI HWY
Mailing Address - Street 2:
Mailing Address - City:ELKTON
Mailing Address - State:MD
Mailing Address - Zip Code:21921-4719
Mailing Address - Country:US
Mailing Address - Phone:410-620-7161
Mailing Address - Fax:410-620-7168
Practice Address - Street 1:1275B W PULASKI HWY
Practice Address - Street 2:
Practice Address - City:ELKTON
Practice Address - State:MD
Practice Address - Zip Code:21921-4719
Practice Address - Country:US
Practice Address - Phone:410-620-7161
Practice Address - Fax:410-620-7168
Is Sole Proprietor?:No
Enumeration Date:2019-01-22
Last Update Date:2019-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDLC9157101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional