Provider Demographics
NPI:1538230123
Name:VANCE, KIMBERLY SUE (MASTER OF EDUCATION)
Entity type:Individual
Prefix:MS
First Name:KIMBERLY
Middle Name:SUE
Last Name:VANCE
Suffix:
Gender:F
Credentials:MASTER OF EDUCATION
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17195 CLEVELAND RD
Mailing Address - Street 2:
Mailing Address - City:SOUTH BEND
Mailing Address - State:IN
Mailing Address - Zip Code:46635-1415
Mailing Address - Country:US
Mailing Address - Phone:574-277-0274
Mailing Address - Fax:574-271-7202
Practice Address - Street 1:17195 CLEVELAND RD
Practice Address - Street 2:
Practice Address - City:SOUTH BEND
Practice Address - State:IN
Practice Address - Zip Code:46635-1415
Practice Address - Country:US
Practice Address - Phone:574-277-0274
Practice Address - Fax:574-271-7202
Is Sole Proprietor?:No
Enumeration Date:2006-11-13
Last Update Date:2024-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN39001136A101Y00000X, 101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000341223OtherANTHEM
IN7381710OtherAETNA
IN200475040Medicaid
IN793356000OtherMAGELLAN