Provider Demographics
NPI:1538564737
Name:VANCE, LEE M (PSYD)
Entity type:Individual
Prefix:MR
First Name:LEE
Middle Name:M
Last Name:VANCE
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22670 SUMMIT DRIVE
Mailing Address - Street 2:SUITE 2
Mailing Address - City:WATERTOWN
Mailing Address - State:NY
Mailing Address - Zip Code:13601
Mailing Address - Country:US
Mailing Address - Phone:315-788-3332
Mailing Address - Fax:315-788-4584
Practice Address - Street 1:22670 SUMMIT DRIVE
Practice Address - Street 2:SUITE 2
Practice Address - City:WATERTOWN
Practice Address - State:NY
Practice Address - Zip Code:13601
Practice Address - Country:US
Practice Address - Phone:315-788-3332
Practice Address - Fax:315-788-4584
Is Sole Proprietor?:No
Enumeration Date:2014-10-30
Last Update Date:2014-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYP94668103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist