Provider Demographics
NPI:1679629810
Name:MILLER, VANESSA MARIE (MA)
Entity Type:Individual
Prefix:
First Name:VANESSA
Middle Name:MARIE
Last Name:MILLER
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:VANESSA
Other - Middle Name:MARIE
Other - Last Name:GATES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:6062 HWY 20 UNIT 35
Mailing Address - Street 2:
Mailing Address - City:PORT TOWNSEND
Mailing Address - State:WA
Mailing Address - Zip Code:98368-9301
Mailing Address - Country:US
Mailing Address - Phone:360-316-6431
Mailing Address - Fax:
Practice Address - Street 1:884 W PARK AVE
Practice Address - Street 2:
Practice Address - City:PORT TOWNSEND
Practice Address - State:WA
Practice Address - Zip Code:98368-2273
Practice Address - Country:US
Practice Address - Phone:360-385-0321
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-27
Last Update Date:2022-01-21
Deactivation Date:2020-03-10
Deactivation Code:
Reactivation Date:2020-03-18
Provider Licenses
StateLicense IDTaxonomies
101Y00000X
WA106S00000X
WAMC61247527101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR197749Medicaid