Provider Demographics
NPI:1912374109
Name:MEDEIROS, VANESSA MARIE (MA)
Entity Type:Individual
Prefix:
First Name:VANESSA
Middle Name:MARIE
Last Name:MEDEIROS
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:789 STEVENS RD
Mailing Address - Street 2:
Mailing Address - City:SWANSEA
Mailing Address - State:MA
Mailing Address - Zip Code:02777-4711
Mailing Address - Country:US
Mailing Address - Phone:508-672-6560
Mailing Address - Fax:
Practice Address - Street 1:789 STEVENS RD
Practice Address - Street 2:
Practice Address - City:SWANSEA
Practice Address - State:MA
Practice Address - Zip Code:02777-4711
Practice Address - Country:US
Practice Address - Phone:508-672-6560
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-08-24
Last Update Date:2015-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes322D00000XResidential Treatment FacilitiesResidential Treatment Facility, Emotionally Disturbed Children