Provider Demographics
NPI:1972883361
Name:VINCENT, ELLEN M (LCDC)
Entity Type:Individual
Prefix:
First Name:ELLEN
Middle Name:M
Last Name:VINCENT
Suffix:
Gender:F
Credentials:LCDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5195 N TRAM RD
Mailing Address - Street 2:
Mailing Address - City:VIDOR
Mailing Address - State:TX
Mailing Address - Zip Code:77662-2406
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2750 S 8TH ST
Practice Address - Street 2:
Practice Address - City:BEAUMONT
Practice Address - State:TX
Practice Address - Zip Code:77701-7719
Practice Address - Country:US
Practice Address - Phone:409-839-1051
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-08-17
Last Update Date:2011-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX10540101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX10540OtherLICENSE NO.