Provider Demographics
NPI:1558904276
Name:MYETTE, VANESSA (MS, BCBA, LABA)
Entity Type:Individual
Prefix:
First Name:VANESSA
Middle Name:
Last Name:MYETTE
Suffix:
Gender:F
Credentials:MS, BCBA, LABA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:275 MEDFORD ST APT 314
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02129-1990
Mailing Address - Country:US
Mailing Address - Phone:617-645-6931
Mailing Address - Fax:
Practice Address - Street 1:1018 MAIN ST
Practice Address - Street 2:
Practice Address - City:WORCESTER
Practice Address - State:MA
Practice Address - Zip Code:01603-2427
Practice Address - Country:US
Practice Address - Phone:774-420-7161
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-10-25
Last Update Date:2019-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA706103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst