Provider Demographics
NPI:1982750980
Name:MATHEWS, VANESSA ANNE
Entity Type:Individual
Prefix:
First Name:VANESSA
Middle Name:ANNE
Last Name:MATHEWS
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 1:2473 LAWTON AVE
Mailing Address - Street 2:
Mailing Address - City:SAN LUIS OBISPO
Mailing Address - State:CA
Mailing Address - Zip Code:93401-5619
Mailing Address - Country:US
Mailing Address - Phone:831-251-0971
Mailing Address - Fax:
Practice Address - Street 1:121 POOLE ST
Practice Address - Street 2:
Practice Address - City:ARROYO GRANDE
Practice Address - State:CA
Practice Address - Zip Code:93420-3324
Practice Address - Country:US
Practice Address - Phone:805-489-9659
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1968Medicare ID - Type UnspecifiedDOCUMENTATION