Basic Information
| Provider Information | |||||||||
| NPI: | 1831580984 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HERRMANN | ||||||||
| FirstName: | VANESSA | ||||||||
| MiddleName: | M | ||||||||
| NamePrefix: | MISS | ||||||||
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| Credential: | M.S. CCC-SLP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 8235 BESSEMER AVE | ||||||||
| Address2: | |||||||||
| City: | NORTH PORT | ||||||||
| State: | FL | ||||||||
| PostalCode: | 342873717 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 1435 COLLINGSWOOD BLVD | ||||||||
| Address2: | SUITE E | ||||||||
| City: | PORT CHARLOTTE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 339481058 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9414850121 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/11/2015 | ||||||||
| LastUpdateDate: | 10/17/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 235Z00000X | SZ7038 | FL | N | Speech, Language and Hearing Service Providers | Speech-Language Pathologist | 235Z00000X | SA14305 | FL | Y | Speech, Language and Hearing Service Providers | Speech-Language Pathologist |
ID Information
| ID | Type | State | Issuer | Description | 014665100 | 05 | FL | MEDICAID |