Provider Demographics
NPI:1356000152
Name:REZCALLAH, VANESSA ANN
Entity Type:Individual
Prefix:
First Name:VANESSA
Middle Name:ANN
Last Name:REZCALLAH
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 1:8280 WILLOW OAKS CORPORATE DR STE 600
Mailing Address - Street 2:
Mailing Address - City:FAIRFAX
Mailing Address - State:VA
Mailing Address - Zip Code:22031-4516
Mailing Address - Country:US
Mailing Address - Phone:202-794-7159
Mailing Address - Fax:
Practice Address - Street 1:18726 S WESTERN AVE
Practice Address - Street 2:
Practice Address - City:GARDENA
Practice Address - State:CA
Practice Address - Zip Code:90248-3813
Practice Address - Country:US
Practice Address - Phone:310-856-0800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-12-09
Last Update Date:2021-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician