Provider Demographics
NPI:1689061434
Name:VON HAGEN, VANESSA (MSS, BCBA)
Entity Type:Individual
Prefix:
First Name:VANESSA
Middle Name:
Last Name:VON HAGEN
Suffix:
Gender:F
Credentials:MSS, BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 51322
Mailing Address - Street 2:
Mailing Address - City:BOWLING GREEN
Mailing Address - State:KY
Mailing Address - Zip Code:42102-5622
Mailing Address - Country:US
Mailing Address - Phone:270-777-9283
Mailing Address - Fax:270-777-9283
Practice Address - Street 1:296 W RIDGE PIKE STE 205
Practice Address - Street 2:
Practice Address - City:LIMERICK
Practice Address - State:PA
Practice Address - Zip Code:19468-1790
Practice Address - Country:US
Practice Address - Phone:610-831-1865
Practice Address - Fax:877-891-3208
Is Sole Proprietor?:No
Enumeration Date:2015-04-20
Last Update Date:2017-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PABH002699103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst