Provider Demographics
NPI:1609368257
Name:WILLMOTH, VANESSA (BCBA)
Entity Type:Individual
Prefix:
First Name:VANESSA
Middle Name:
Last Name:WILLMOTH
Suffix:
Gender:F
Credentials:BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1155 MILL ST # MCM14
Mailing Address - Street 2:
Mailing Address - City:RENO
Mailing Address - State:NV
Mailing Address - Zip Code:89502-1576
Mailing Address - Country:US
Mailing Address - Phone:775-982-5262
Mailing Address - Fax:775-982-3900
Practice Address - Street 1:75 PRINGLE WAY STE 300
Practice Address - Street 2:
Practice Address - City:RENO
Practice Address - State:NV
Practice Address - Zip Code:89502-8425
Practice Address - Country:US
Practice Address - Phone:775-982-3960
Practice Address - Fax:775-982-3971
Is Sole Proprietor?:No
Enumeration Date:2018-05-30
Last Update Date:2022-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVLBA0540103K00000X, 103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV1609368257Medicaid