Basic Information
| Provider Information | |||||||||
| NPI: | 1588782395 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | VANNESS | ||||||||
| FirstName: | MICHELLE | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MRS. | ||||||||
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| Credential: | MFT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2100 5TH STREET | ||||||||
| Address2: | MS 5-230 | ||||||||
| City: | DAVIS | ||||||||
| State: | CA | ||||||||
| PostalCode: | 95616 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5307473400 | ||||||||
| FaxNumber: | 5307530398 | ||||||||
| Practice Location | |||||||||
| Address1: | 2100 5TH STREET | ||||||||
| Address2: | MS 5-230 | ||||||||
| City: | DAVIS | ||||||||
| State: | CA | ||||||||
| PostalCode: | 95616 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5307473400 | ||||||||
| FaxNumber: | 5307530398 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/27/2007 | ||||||||
| LastUpdateDate: | 07/27/2011 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | MFC42935 | CA | N | Behavioral Health & Social Service Providers | Counselor | Mental Health | 106H00000X | 42935 | CA | Y | Behavioral Health & Social Service Providers | Marriage & Family Therapist |
No ID Information.