Healthcare Provider Details

I. General information

NPI: 1205466059
Provider Name (Legal Business Name): VANESSA AYALA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/21/2020
Last Update Date: 06/30/2024
Certification Date: 09/26/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

901 W VICTORIA ST # FG
COMPTON CA
90220-5807
US

IV. Provider business mailing address

901 W VICTORIA ST # FG
COMPTON CA
90220-5807
US

V. Phone/Fax

Practice location:
  • Phone: 310-669-9510
  • Fax:
Mailing address:
  • Phone: 310-669-9510
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number117072
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number123324
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: