Provider Demographics
NPI:1356888077
Name:VANCE, ELISABETH ANGELICA (SLP)
Entity type:Individual
Prefix:
First Name:ELISABETH
Middle Name:ANGELICA
Last Name:VANCE
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:150 POINT O'WOODS RD.
Mailing Address - Street 2:
Mailing Address - City:WILLIAMSBURG
Mailing Address - State:VA
Mailing Address - Zip Code:23188-7052
Mailing Address - Country:US
Mailing Address - Phone:757-566-3300
Mailing Address - Fax:757-566-8977
Practice Address - Street 1:150 POINT O'WOODS RD.
Practice Address - Street 2:
Practice Address - City:WILLIAMSBURG
Practice Address - State:VA
Practice Address - Zip Code:23188-7052
Practice Address - Country:US
Practice Address - Phone:757-566-3300
Practice Address - Fax:757-566-8977
Is Sole Proprietor?:No
Enumeration Date:2017-01-20
Last Update Date:2017-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2202008458235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA45084OtherOPTIMA
VA49-7850-1Medicaid
VA49-6679Medicare PIN