Provider Demographics
NPI:1245720481
Name:BAHENA, VANESSA (RBT)
Entity type:Individual
Prefix:
First Name:VANESSA
Middle Name:
Last Name:BAHENA
Suffix:
Gender:F
Credentials:RBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:828 W PACIFIC AVE
Mailing Address - Street 2:
Mailing Address - City:WAUKEGAN
Mailing Address - State:IL
Mailing Address - Zip Code:60085-1830
Mailing Address - Country:US
Mailing Address - Phone:224-944-9175
Mailing Address - Fax:
Practice Address - Street 1:828 W PACIFIC AVE
Practice Address - Street 2:
Practice Address - City:WAUKEGAN
Practice Address - State:IL
Practice Address - Zip Code:60085-1830
Practice Address - Country:US
Practice Address - Phone:224-944-9175
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-14
Last Update Date:2018-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
18-51098106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician