Basic Information
| Provider Information | |||||||||
| NPI: | 1982182846 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LIGHTFOOT | ||||||||
| FirstName: | VANESSA | ||||||||
| MiddleName: | BROOKE | ||||||||
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| Credential: | BASW AARC CDP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 410 S WILBUR AVE | ||||||||
| Address2: | |||||||||
| City: | WALLA WALLA | ||||||||
| State: | WA | ||||||||
| PostalCode: | 993623532 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5095296036 | ||||||||
| FaxNumber: | 8559270099 | ||||||||
| Practice Location | |||||||||
| Address1: | 2802 BROADWAY | ||||||||
| Address2: | |||||||||
| City: | EVERETT | ||||||||
| State: | WA | ||||||||
| PostalCode: | 982013642 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4252593191 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/02/2018 | ||||||||
| LastUpdateDate: | 09/19/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 09/19/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | 6082656 | WA | N | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | 101YM0800X | CG6083778 | WA | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.