Provider Demographics
NPI:1528559432
Name:DYSIN, VANESSA
Entity Type:Individual
Prefix:
First Name:VANESSA
Middle Name:
Last Name:DYSIN
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 1:1717 MYRTLE ST APT B
Mailing Address - Street 2:
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94607-3356
Mailing Address - Country:US
Mailing Address - Phone:510-274-8292
Mailing Address - Fax:
Practice Address - Street 1:2821 CROW CANYON RD STE 101
Practice Address - Street 2:
Practice Address - City:SAN RAMON
Practice Address - State:CA
Practice Address - Zip Code:94583-1659
Practice Address - Country:US
Practice Address - Phone:510-999-4410
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-05-25
Last Update Date:2018-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician