Healthcare Provider Details

I. General information

NPI: 1568308526
Provider Name (Legal Business Name): DEDRIC VANN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/23/2026
Last Update Date: 04/23/2026
Certification Date: 04/23/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

29404 PACIFIC HWY S APT 302
FEDERAL WAY WA
98003-4152
US

IV. Provider business mailing address

29404 PACIFIC HWY S APT 302
FEDERAL WAY WA
98003-4152
US

V. Phone/Fax

Practice location:
  • Phone: 253-569-6105
  • Fax:
Mailing address:
  • Phone: 253-569-6105
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: