Basic Information
| Provider Information | |||||||||
| NPI: | 1639422009 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ZIZAK | ||||||||
| FirstName: | VANESSA | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | VA LONG BEACH HEALTHCARE SYSTEM | ||||||||
| Address2: | 5901 EAST 7TH ST. MAILBOX 116B | ||||||||
| City: | LONG BEACH | ||||||||
| State: | CA | ||||||||
| PostalCode: | 90822 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5628268000 | ||||||||
| FaxNumber: | 5628265679 | ||||||||
| Practice Location | |||||||||
| Address1: | VA LONG BEACH HEALTHCARE SYSTEM | ||||||||
| Address2: | 5901 EAST 7TH ST. MAILBOX 116B | ||||||||
| City: | LONG BEACH | ||||||||
| State: | CA | ||||||||
| PostalCode: | 90822 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5628268000 | ||||||||
| FaxNumber: | 5628265679 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/22/2012 | ||||||||
| LastUpdateDate: | 03/13/2015 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103G00000X | PSY26871 | CA | Y | Behavioral Health & Social Service Providers | Clinical Neuropsychologist | 103T00000X | PSY26871 | CA | N | Behavioral Health & Social Service Providers | Psychologist | 103G00000X | 4334 | AZ | N | Behavioral Health & Social Service Providers | Clinical Neuropsychologist | 103TC0700X | 4334 | AZ | N | Behavioral Health & Social Service Providers | Psychologist | Clinical |
No ID Information.