Provider Demographics
NPI:1184135477
Name:MYERS, VANESSA IVY (AAS, CRM)
Entity type:Individual
Prefix:
First Name:VANESSA
Middle Name:IVY
Last Name:MYERS
Suffix:
Gender:F
Credentials:AAS, CRM
Other - Prefix:
Other - First Name:IVY
Other - Middle Name:
Other - Last Name:MYERS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:AAS, CRM
Mailing Address - Street 1:3159 NE 13TH PL
Mailing Address - Street 2:
Mailing Address - City:HILLSBORO
Mailing Address - State:OR
Mailing Address - Zip Code:97124-4074
Mailing Address - Country:US
Mailing Address - Phone:503-619-7877
Mailing Address - Fax:
Practice Address - Street 1:152 SE 5TH AVE
Practice Address - Street 2:
Practice Address - City:HILLSBORO
Practice Address - State:OR
Practice Address - Zip Code:97123-4293
Practice Address - Country:US
Practice Address - Phone:971-202-7881
Practice Address - Fax:503-746-5617
Is Sole Proprietor?:Yes
Enumeration Date:2017-10-13
Last Update Date:2019-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YA0400X
OR17-CRM-038175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)