Provider Demographics
NPI:1336257526
Name:VAN DIS, ANNA C (LCSW)
Entity Type:Individual
Prefix:
First Name:ANNA
Middle Name:C
Last Name:VAN DIS
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:402 TRENT DRIVE
Mailing Address - Street 2:
Mailing Address - City:DURHAM
Mailing Address - State:NC
Mailing Address - Zip Code:27705
Mailing Address - Country:US
Mailing Address - Phone:919-668-5559
Mailing Address - Fax:919-668-4496
Practice Address - Street 1:402 TRENT DRIVE
Practice Address - Street 2:
Practice Address - City:DURHAM
Practice Address - State:NC
Practice Address - Zip Code:27705
Practice Address - Country:US
Practice Address - Phone:919-668-5559
Practice Address - Fax:919-668-4496
Is Sole Proprietor?:No
Enumeration Date:2006-08-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCC0045601041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6002826Medicare ID - Type Unspecified