Provider Demographics
NPI:1073962437
Name:RISINGMOON, VANESSA
Entity Type:Individual
Prefix:
First Name:VANESSA
Middle Name:
Last Name:RISINGMOON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:897 TANNER DR
Mailing Address - Street 2:
Mailing Address - City:SCOTTDALE
Mailing Address - State:GA
Mailing Address - Zip Code:30079-1036
Mailing Address - Country:US
Mailing Address - Phone:800-381-2195
Mailing Address - Fax:888-381-0822
Practice Address - Street 1:4500 SATELLITE BLVD
Practice Address - Street 2:STE 2250
Practice Address - City:DULUTH
Practice Address - State:GA
Practice Address - Zip Code:30096-5037
Practice Address - Country:US
Practice Address - Phone:800-381-2195
Practice Address - Fax:888-381-0822
Is Sole Proprietor?:Yes
Enumeration Date:2016-06-07
Last Update Date:2016-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GASLP009220235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist