Provider Demographics
NPI:1821700253
Name:SMITH, VANESSA
Entity Type:Individual
Prefix:
First Name:VANESSA
Middle Name:
Last Name:SMITH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14834 W WINDSOR AVE
Mailing Address - Street 2:
Mailing Address - City:GOODYEAR
Mailing Address - State:AZ
Mailing Address - Zip Code:85395-8497
Mailing Address - Country:US
Mailing Address - Phone:602-580-6457
Mailing Address - Fax:
Practice Address - Street 1:14834 W WINDSOR AVE
Practice Address - Street 2:
Practice Address - City:GOODYEAR
Practice Address - State:AZ
Practice Address - Zip Code:85395-8497
Practice Address - Country:US
Practice Address - Phone:602-580-6457
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-12-16
Last Update Date:2022-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZB57849732101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselorGroup - Single Specialty