Provider Demographics
NPI:1386402832
Name:VANCE, BRENDA (LPC)
Entity type:Individual
Prefix:
First Name:BRENDA
Middle Name:
Last Name:VANCE
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10 CARI CT
Mailing Address - Street 2:
Mailing Address - City:DEKALB
Mailing Address - State:IL
Mailing Address - Zip Code:60115-1014
Mailing Address - Country:US
Mailing Address - Phone:815-901-4486
Mailing Address - Fax:
Practice Address - Street 1:15 S OLD STATE CAPITOL PLZ
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:IL
Practice Address - Zip Code:62701-1567
Practice Address - Country:US
Practice Address - Phone:815-993-8724
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-03-11
Last Update Date:2024-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL178.020002101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty