Provider Demographics
NPI:1033853924
Name:VALLE, VANESSA M (LMT)
Entity Type:Individual
Prefix:
First Name:VANESSA
Middle Name:M
Last Name:VALLE
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1455 W PARK AVE
Mailing Address - Street 2:
Mailing Address - City:REDLANDS
Mailing Address - State:CA
Mailing Address - Zip Code:92373-8178
Mailing Address - Country:US
Mailing Address - Phone:909-793-1334
Mailing Address - Fax:909-793-2221
Practice Address - Street 1:1455 W PARK AVE
Practice Address - Street 2:
Practice Address - City:REDLANDS
Practice Address - State:CA
Practice Address - Zip Code:92373-8178
Practice Address - Country:US
Practice Address - Phone:909-793-1334
Practice Address - Fax:909-793-2221
Is Sole Proprietor?:Yes
Enumeration Date:2022-04-26
Last Update Date:2022-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA48936225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist