Provider Demographics
NPI:1083050629
Name:ARCHULETA, VANESSA ELIZABETH
Entity Type:Individual
Prefix:MISS
First Name:VANESSA
Middle Name:ELIZABETH
Last Name:ARCHULETA
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 1:2864 CANDLEBERRY WAY
Mailing Address - Street 2:
Mailing Address - City:FAIRFIELD
Mailing Address - State:CA
Mailing Address - Zip Code:94533-7029
Mailing Address - Country:US
Mailing Address - Phone:707-816-2494
Mailing Address - Fax:
Practice Address - Street 1:2864 CANDLEBERRY WAY
Practice Address - Street 2:
Practice Address - City:FAIRFIELD
Practice Address - State:CA
Practice Address - Zip Code:94533-7029
Practice Address - Country:US
Practice Address - Phone:707-816-2494
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-05-21
Last Update Date:2016-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
CAD4094674103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health