Provider Demographics
NPI:1679046478
Name:BERESFORD, VANESSA KALINE
Entity Type:Individual
Prefix:
First Name:VANESSA
Middle Name:KALINE
Last Name:BERESFORD
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:VANESSA
Other - Middle Name:
Other - Last Name:KALINE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:AMFT, APCC
Mailing Address - Street 1:PO BOX 172
Mailing Address - Street 2:
Mailing Address - City:SAN CARLOS
Mailing Address - State:CA
Mailing Address - Zip Code:94070-0172
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:335 QUARRY RD
Practice Address - Street 2:
Practice Address - City:SAN CARLOS
Practice Address - State:CA
Practice Address - Zip Code:94070-6217
Practice Address - Country:US
Practice Address - Phone:650-591-3636
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-04
Last Update Date:2019-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA5306101YM0800X
CA170534106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health