Provider Demographics
NPI:1962179820
Name:VANCE, SHONNA (LCSW)
Entity type:Individual
Prefix:
First Name:SHONNA
Middle Name:
Last Name:VANCE
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 1:7526 TRYON RD # 1054
Mailing Address - Street 2:
Mailing Address - City:JUDSON
Mailing Address - State:TX
Mailing Address - Zip Code:75660-5048
Mailing Address - Country:US
Mailing Address - Phone:903-399-1086
Mailing Address - Fax:
Practice Address - Street 1:1112 JORDAN ST
Practice Address - Street 2:
Practice Address - City:LONGVIEW
Practice Address - State:TX
Practice Address - Zip Code:75602-2232
Practice Address - Country:US
Practice Address - Phone:903-399-1086
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-26
Last Update Date:2021-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX213781041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical