Provider Demographics
NPI:1245856632
Name:VANESSA IVERSON, LLC
Entity type:Organization
Organization Name:VANESSA IVERSON, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/THERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:VANESSA
Authorized Official - Middle Name:
Authorized Official - Last Name:IVERSON
Authorized Official - Suffix:
Authorized Official - Credentials:MA, LPC
Authorized Official - Phone:605-670-3104
Mailing Address - Street 1:115 S MAIN AVE
Mailing Address - Street 2:
Mailing Address - City:WAGNER
Mailing Address - State:SD
Mailing Address - Zip Code:57380-2001
Mailing Address - Country:US
Mailing Address - Phone:605-670-3104
Mailing Address - Fax:
Practice Address - Street 1:115 S MAIN AVE
Practice Address - Street 2:
Practice Address - City:WAGNER
Practice Address - State:SD
Practice Address - Zip Code:57380-2001
Practice Address - Country:US
Practice Address - Phone:605-670-3104
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-06-22
Last Update Date:2020-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty