Provider Demographics
NPI:1164995593
Name:VANEM, KERSTEN (MS PMHT)
Entity Type:Individual
Prefix:
First Name:KERSTEN
Middle Name:
Last Name:VANEM
Suffix:
Gender:F
Credentials:MS PMHT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:706 HIGHWAY 51 N
Mailing Address - Street 2:
Mailing Address - City:BROOKHAVEN
Mailing Address - State:MS
Mailing Address - Zip Code:39601-2366
Mailing Address - Country:US
Mailing Address - Phone:601-990-2513
Mailing Address - Fax:
Practice Address - Street 1:706 HIGHWAY 51 N
Practice Address - Street 2:
Practice Address - City:BROOKHAVEN
Practice Address - State:MS
Practice Address - Zip Code:39601-2366
Practice Address - Country:US
Practice Address - Phone:601-990-2513
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-08
Last Update Date:2019-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA600950849Medicaid