Provider Demographics
NPI:1720224918
Name:GRANDE, VANESSA (MS, SLP - TSLD)
Entity Type:Individual
Prefix:
First Name:VANESSA
Middle Name:
Last Name:GRANDE
Suffix:
Gender:F
Credentials:MS, SLP - TSLD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11607 LITTLE BAY HARBOR WAY
Mailing Address - Street 2:
Mailing Address - City:SPOTSYLVANIA
Mailing Address - State:VA
Mailing Address - Zip Code:22551-8905
Mailing Address - Country:US
Mailing Address - Phone:914-589-9815
Mailing Address - Fax:540-412-5818
Practice Address - Street 1:11607 LITTLE BAY HARBOR WAY
Practice Address - Street 2:
Practice Address - City:SPOTSYLVANIA
Practice Address - State:VA
Practice Address - Zip Code:22551-8905
Practice Address - Country:US
Practice Address - Phone:914-589-9815
Practice Address - Fax:540-412-5818
Is Sole Proprietor?:No
Enumeration Date:2008-12-18
Last Update Date:2013-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2202006582235Z00000X
NY012371235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VATONATIUH2010Medicaid