Provider Demographics
NPI:1275679391
Name:DANCE, JAMES A (DMIN)
Entity Type:Individual
Prefix:DR
First Name:JAMES
Middle Name:A
Last Name:DANCE
Suffix:
Gender:M
Credentials:DMIN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6612 TRALEE CT
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46835-9662
Mailing Address - Country:US
Mailing Address - Phone:260-486-1089
Mailing Address - Fax:
Practice Address - Street 1:300 W WAYNE ST
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46802-3608
Practice Address - Country:US
Practice Address - Phone:260-422-8556
Practice Address - Fax:260-422-8558
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-29
Last Update Date:2008-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN39000394A101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN00055OtherICAC-II
IN39000394AOtherMENTAL HEALTH LICENSE