Provider Demographics
NPI:1881943157
Name:VANN, ANDRE SPENCER (,MSW, LCSW, LCAS)
Entity type:Individual
Prefix:
First Name:ANDRE
Middle Name:SPENCER
Last Name:VANN
Suffix:
Gender:M
Credentials:,MSW, LCSW, LCAS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:308 E SPRING ST
Mailing Address - Street 2:
Mailing Address - City:WAKE FOREST
Mailing Address - State:NC
Mailing Address - Zip Code:27587-2640
Mailing Address - Country:US
Mailing Address - Phone:919-398-5512
Mailing Address - Fax:919-526-9198
Practice Address - Street 1:202 S MAIN ST
Practice Address - Street 2:
Practice Address - City:LOUISBURG
Practice Address - State:NC
Practice Address - Zip Code:27549-2522
Practice Address - Country:US
Practice Address - Phone:919-435-8164
Practice Address - Fax:919-526-9198
Is Sole Proprietor?:Yes
Enumeration Date:2012-09-02
Last Update Date:2022-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2658101YA0400X
NCC0083941041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC179YXOtherBCBS
NC6112368Medicaid
NCQ441250281Medicare UPIN