Provider Demographics
NPI:1245313360
Name:BLANC, VIVIAN LEDERER (MS)
Entity type:Individual
Prefix:MS
First Name:VIVIAN
Middle Name:LEDERER
Last Name:BLANC
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1017 MUMMA RD
Mailing Address - Street 2:SUITE 200
Mailing Address - City:WORMLEYSBURG
Mailing Address - State:PA
Mailing Address - Zip Code:17043-1145
Mailing Address - Country:US
Mailing Address - Phone:717-303-5960
Mailing Address - Fax:717-303-5962
Practice Address - Street 1:1017 MUMMA RD
Practice Address - Street 2:SUITE 200
Practice Address - City:WORMLEYSBURG
Practice Address - State:PA
Practice Address - Zip Code:17043-1145
Practice Address - Country:US
Practice Address - Phone:717-303-5960
Practice Address - Fax:717-303-5962
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-23
Last Update Date:2011-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPC002092101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional