Healthcare Provider Details

I. General information

NPI: 1255520771
Provider Name (Legal Business Name): VICTORIA V VANCE MFT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/21/2007
Last Update Date: 10/21/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

582 INDIANOLA RD
BAYSIDE CA
95524-9334
US

IV. Provider business mailing address

582 INDIANOLA RD
BAYSIDE CA
95524-9334
US

V. Phone/Fax

Practice location:
  • Phone: 707-269-0635
  • Fax: 707-269-0635
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License NumberMFC36852
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: