1588019145 NPI number — VANESSA ELOISE HERNANDEZ LISAC LAC

Table of content: TABATHA BOTTINI (NPI 1316685340)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1588019145 NPI number — VANESSA ELOISE HERNANDEZ LISAC LAC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
HERNANDEZ
Provider First Name:
VANESSA
Provider Middle Name:
ELOISE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
LISAC LAC
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
PHILLIPS
Provider Other First Name:
VANESSA
Provider Other Middle Name:
ELOISE
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
LISAC LAC
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1588019145
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/02/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4108 S. ADELLE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MESA
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
85212
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
609-412-0853
Provider Business Mailing Address Fax Number:
602-595-2511

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
10000 N. 31ST AVE.
Provider Second Line Business Practice Location Address:
APPLIED BEHAVIORAL INTERVENTIONS, PLLC
Provider Business Practice Location Address City Name:
PHOENIX
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
85051
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
609-412-0853
Provider Business Practice Location Address Fax Number:
602-595-2511
Provider Enumeration Date:
05/02/2016

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 101YA0400X , with the licence number:  LISAC15037 , registered in the state of AZ ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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