Provider Demographics
NPI:1871696161
Name:VANCE, ANGELA M (LCSW)
Entity type:Individual
Prefix:
First Name:ANGELA
Middle Name:M
Last Name:VANCE
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 1:242 HENRY ST
Mailing Address - Street 2:SUITE A
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11201-4608
Mailing Address - Country:US
Mailing Address - Phone:718-625-0537
Mailing Address - Fax:718-625-0612
Practice Address - Street 1:242 HENRY ST
Practice Address - Street 2:SUITE A
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11201-4608
Practice Address - Country:US
Practice Address - Phone:718-625-0537
Practice Address - Fax:718-625-0612
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYR0144541041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYR014454OtherSTATE LICENSE
NO8171Medicare ID - Type UnspecifiedMEDICARE NUMBER