Provider Demographics
NPI:1669825451
Name:MATOSSIAN, VANESSA (MS, LPC)
Entity Type:Individual
Prefix:
First Name:VANESSA
Middle Name:
Last Name:MATOSSIAN
Suffix:
Gender:F
Credentials:MS, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:320 N GARFIELD ST
Mailing Address - Street 2:
Mailing Address - City:MOSCOW
Mailing Address - State:ID
Mailing Address - Zip Code:83843-3666
Mailing Address - Country:US
Mailing Address - Phone:208-596-9971
Mailing Address - Fax:
Practice Address - Street 1:317 W 6TH ST STE 208
Practice Address - Street 2:
Practice Address - City:MOSCOW
Practice Address - State:ID
Practice Address - Zip Code:83843-2387
Practice Address - Country:US
Practice Address - Phone:208-882-3504
Practice Address - Fax:208-882-3572
Is Sole Proprietor?:No
Enumeration Date:2016-07-18
Last Update Date:2016-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLPC-6260101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional