Provider Demographics
NPI:1407502586
Name:MCCLINTOCK, VANESSA (MA, LPC)
Entity Type:Individual
Prefix:
First Name:VANESSA
Middle Name:
Last Name:MCCLINTOCK
Suffix:
Gender:F
Credentials:MA, LPC
Other - Prefix:
Other - First Name:VANESSA
Other - Middle Name:
Other - Last Name:CAVANAUGH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:61 S MAIN ST STE 214
Mailing Address - Street 2:
Mailing Address - City:WEST HARTFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06107-2486
Mailing Address - Country:US
Mailing Address - Phone:860-969-2399
Mailing Address - Fax:860-215-3016
Practice Address - Street 1:61 S MAIN ST STE 214
Practice Address - Street 2:
Practice Address - City:WEST HARTFORD
Practice Address - State:CT
Practice Address - Zip Code:06107-2486
Practice Address - Country:US
Practice Address - Phone:860-969-2399
Practice Address - Fax:860-215-3016
Is Sole Proprietor?:Yes
Enumeration Date:2022-02-27
Last Update Date:2023-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT5204101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional