Provider Demographics
NPI:1093589764
Name:VENEGAS, AVA ROSE YAN YAN
Entity Type:Individual
Prefix:
First Name:AVA ROSE
Middle Name:YAN YAN
Last Name:VENEGAS
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 1:3717 BLAISDELL AVE
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55409-1214
Mailing Address - Country:US
Mailing Address - Phone:651-300-7166
Mailing Address - Fax:
Practice Address - Street 1:6320 PENN AVE S
Practice Address - Street 2:
Practice Address - City:RICHFIELD
Practice Address - State:MN
Practice Address - Zip Code:55423-1139
Practice Address - Country:US
Practice Address - Phone:612-677-2350
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-11-13
Last Update Date:2023-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician