Provider Demographics
NPI:1710051719
Name:KOUTALIDIS, VANESSA LEIGH (DC)
Entity Type:Individual
Prefix:DR
First Name:VANESSA
Middle Name:LEIGH
Last Name:KOUTALIDIS
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1749 NE 26TH STREET
Mailing Address - Street 2:SUITE F
Mailing Address - City:WILTON MANORS
Mailing Address - State:FL
Mailing Address - Zip Code:33305
Mailing Address - Country:US
Mailing Address - Phone:954-566-1349
Mailing Address - Fax:954-566-1385
Practice Address - Street 1:1749 NE 26TH STREET
Practice Address - Street 2:SUITE F
Practice Address - City:WILTON MANORS
Practice Address - State:FL
Practice Address - Zip Code:33305
Practice Address - Country:US
Practice Address - Phone:954-566-1349
Practice Address - Fax:954-566-1385
Is Sole Proprietor?:No
Enumeration Date:2006-11-20
Last Update Date:2013-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCH7318111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
70635OtherBC
U59041Medicare UPIN
70635OtherBC