Provider Demographics
NPI:1487787610
Name:THEOPHIN-MICHEL, VANDA (LCSW)
Entity type:Individual
Prefix:MRS
First Name:VANDA
Middle Name:
Last Name:THEOPHIN-MICHEL
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21033 PINE KNOT LN
Mailing Address - Street 2:
Mailing Address - City:LAND O LAKES
Mailing Address - State:FL
Mailing Address - Zip Code:34637-7827
Mailing Address - Country:US
Mailing Address - Phone:919-339-8611
Mailing Address - Fax:919-400-4210
Practice Address - Street 1:21033 PINE KNOT LN
Practice Address - Street 2:
Practice Address - City:LAND O LAKES
Practice Address - State:FL
Practice Address - Zip Code:34637-7827
Practice Address - Country:US
Practice Address - Phone:919-339-8611
Practice Address - Fax:919-400-4210
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-14
Last Update Date:2017-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCC0061991041C0700X
FLSW85371041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6007310Medicaid
FL768216600Medicaid