Provider Demographics
NPI:1679044663
Name:IVERSON, VANESSA (LPC-MH)
Entity Type:Individual
Prefix:
First Name:VANESSA
Middle Name:
Last Name:IVERSON
Suffix:
Gender:F
Credentials:LPC-MH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:111 WASHINGTON AVE NW
Mailing Address - Street 2:
Mailing Address - City:WAGNER
Mailing Address - State:SD
Mailing Address - Zip Code:57380-4300
Mailing Address - Country:US
Mailing Address - Phone:605-384-3621
Mailing Address - Fax:
Practice Address - Street 1:111 WASHINGTON AVE NW
Practice Address - Street 2:
Practice Address - City:WAGNER
Practice Address - State:SD
Practice Address - Zip Code:57380-4300
Practice Address - Country:US
Practice Address - Phone:605-384-3621
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-12-17
Last Update Date:2021-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SDLPC20379101YP2500X
SDLPC-MH30619101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional