Provider Demographics
NPI:1447494737
Name:VANCE, KATHERINE AILEEN (LMSW)
Entity type:Individual
Prefix:
First Name:KATHERINE
Middle Name:AILEEN
Last Name:VANCE
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3312 HICKORY DR
Mailing Address - Street 2:
Mailing Address - City:LAKE ORION
Mailing Address - State:MI
Mailing Address - Zip Code:48359-1165
Mailing Address - Country:US
Mailing Address - Phone:248-224-1626
Mailing Address - Fax:
Practice Address - Street 1:10 W SQUARE LAKE RD
Practice Address - Street 2:SUITE 103
Practice Address - City:BLOOMFIELD HILLS
Practice Address - State:MI
Practice Address - Zip Code:48302-0465
Practice Address - Country:US
Practice Address - Phone:248-716-9773
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-04-30
Last Update Date:2015-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI215435751041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical