=====================================================
General NPI Number Information
=====================================================
NPI Number | 1336342740
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JAMES EDWARD VANCE MA, LPC, CCAC, LSW,
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/06/2007
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1000 CENTRE WAY
-----------------------------------------------------
City | CHARLESTON
-----------------------------------------------------
State | WV
-----------------------------------------------------
Zip | 25309-9426
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 304-746-5166
-----------------------------------------------------
Fax | 304-746-5279
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 308 MONROE ST
-----------------------------------------------------
City | SOUTH CHARLESTON
-----------------------------------------------------
State | WV
-----------------------------------------------------
Zip | 25303-1801
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 304-746-5166
-----------------------------------------------------
Fax | 304-746-5279
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number | WV376
-----------------------------------------------------
License Number State | WV
-----------------------------------------------------