Provider Demographics
NPI:1609451186
Name:DAVIS, VANESSA
Entity Type:Individual
Prefix:
First Name:VANESSA
Middle Name:
Last Name:DAVIS
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 1:1195A CITY VIEW ST
Mailing Address - Street 2:
Mailing Address - City:EUGENE
Mailing Address - State:OR
Mailing Address - Zip Code:97402-3325
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:621 W MADRONE ST
Practice Address - Street 2:
Practice Address - City:ROSEBURG
Practice Address - State:OR
Practice Address - Zip Code:97470-3090
Practice Address - Country:US
Practice Address - Phone:541-672-2691
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-03-16
Last Update Date:2023-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR23-QMHA-R-3548101YM0800X
ORT-23-2338101YA0400X
175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No175T00000XOther Service ProvidersPeer Specialist