Provider Demographics
NPI:1144716549
Name:VANCE MARRIAGE AND FAMILY THERAPY, INC.
Entity type:Organization
Organization Name:VANCE MARRIAGE AND FAMILY THERAPY, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:CAROLE
Authorized Official - Middle Name:
Authorized Official - Last Name:VANCE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:209-598-1630
Mailing Address - Street 1:1545 SAINT MARKS PLZ STE 5
Mailing Address - Street 2:
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95207-6411
Mailing Address - Country:US
Mailing Address - Phone:209-598-1630
Mailing Address - Fax:209-955-1050
Practice Address - Street 1:1545 SAINT MARKS PLZ STE 5
Practice Address - Street 2:
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95207-6411
Practice Address - Country:US
Practice Address - Phone:209-598-1630
Practice Address - Fax:209-955-1050
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-07-09
Last Update Date:2018-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA43158261QM0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)