Healthcare Provider Details

I. General information

NPI: 1831344670
Provider Name (Legal Business Name): AMY C VANCE LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/20/2008
Last Update Date: 03/20/2025
Certification Date: 03/20/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11518 N PORT WASHINGTON RD STE 202
MEQUON WI
53092-3443
US

IV. Provider business mailing address

5330 N NAVAJO AVE
GLENDALE WI
53217-5035
US

V. Phone/Fax

Practice location:
  • Phone: 262-999-3495
  • Fax:
Mailing address:
  • Phone: 503-277-3522
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number12156-123
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number StateOR
# 3
Primary TaxonomyN
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number15717
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: