Provider Demographics
NPI:1952759052
Name:WISSLER, VANESSA ROSE
Entity Type:Individual
Prefix:
First Name:VANESSA
Middle Name:ROSE
Last Name:WISSLER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1969 SW PARK AVE APT 706
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97201-3167
Mailing Address - Country:US
Mailing Address - Phone:408-693-0270
Mailing Address - Fax:
Practice Address - Street 1:2120 SW JEFFERSON ST
Practice Address - Street 2:SUITE B200
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97201-7727
Practice Address - Country:US
Practice Address - Phone:503-244-4083
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-05-30
Last Update Date:2017-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVRBT-16-20405103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst