Provider Demographics
NPI:1760940423
Name:COLLIS, VANESSA VIZCAINO (RADT-1)
Entity Type:Individual
Prefix:
First Name:VANESSA
Middle Name:VIZCAINO
Last Name:COLLIS
Suffix:
Gender:F
Credentials:RADT-1
Other - Prefix:
Other - First Name:VANESSA
Other - Middle Name:VIZCAINO
Other - Last Name:COLLIS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:VANESSA COLLIS
Mailing Address - Street 1:550 W WASHINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:ESCONDIDO
Mailing Address - State:CA
Mailing Address - Zip Code:92025-1643
Mailing Address - Country:US
Mailing Address - Phone:760-489-6380
Mailing Address - Fax:
Practice Address - Street 1:550 W WASHINGTON AVE
Practice Address - Street 2:
Practice Address - City:ESCONDIDO
Practice Address - State:CA
Practice Address - Zip Code:92025-1643
Practice Address - Country:US
Practice Address - Phone:760-489-6380
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-12
Last Update Date:2019-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA370093BN101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)