Provider Demographics
NPI:1619582558
Name:BERMUDEZ, VANESSA
Entity Type:Individual
Prefix:
First Name:VANESSA
Middle Name:
Last Name:BERMUDEZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:VANESSA
Other - Middle Name:
Other - Last Name:DIAZ VENEGAS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:1625 W OLYMPIC BLVD STE 600
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90015-3865
Mailing Address - Country:US
Mailing Address - Phone:323-999-2404
Mailing Address - Fax:
Practice Address - Street 1:1625 W OLYMPIC BLVD STE 600
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90015-3865
Practice Address - Country:US
Practice Address - Phone:323-999-2404
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-08
Last Update Date:2023-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA100521101YM0800X, 104100000X
101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional