Provider Demographics
NPI:1780351569
Name:MENA-GIBSON, VANESSA (LICSW)
Entity type:Individual
Prefix:MS
First Name:VANESSA
Middle Name:
Last Name:MENA-GIBSON
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:415 SOUTH ST
Mailing Address - Street 2:
Mailing Address - City:WALTHAM
Mailing Address - State:MA
Mailing Address - Zip Code:02453-2700
Mailing Address - Country:US
Mailing Address - Phone:781-736-3723
Mailing Address - Fax:
Practice Address - Street 1:415 SOUTH ST
Practice Address - Street 2:
Practice Address - City:WALTHAM
Practice Address - State:MA
Practice Address - Zip Code:02453-2700
Practice Address - Country:US
Practice Address - Phone:781-736-3723
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-27
Last Update Date:2021-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1236911041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical