Basic Information
Provider Information | |||||||||
NPI: | 1013240050 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | VANCE | ||||||||
FirstName: | ANGELA | ||||||||
MiddleName: | DAWN | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | LMSW | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | WEBB | ||||||||
OtherFirstName: | ANGELA | ||||||||
OtherMiddleName: | DAWN | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 6350 W ANDREW JOHNSON HWY | ||||||||
Address2: | DEPARTMENT 100 | ||||||||
City: | TALBOTT | ||||||||
State: | TN | ||||||||
PostalCode: | 378778605 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8003553565 | ||||||||
FaxNumber: | 4237142355 | ||||||||
Practice Location | |||||||||
Address1: | 10731 CHAPMAN HWY | ||||||||
Address2: |   | ||||||||
City: | SEYMOUR | ||||||||
State: | TN | ||||||||
PostalCode: | 378654765 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8655730698 | ||||||||
FaxNumber: | 8655733174 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 09/09/2009 | ||||||||
LastUpdateDate: | 03/02/2015 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 104100000X |   | TN | N |   | Behavioral Health & Social Service Providers | Social Worker |   | 104100000X | 8140 | TN | Y |   | Behavioral Health & Social Service Providers | Social Worker |   |
No ID Information.