Healthcare Provider Details

I. General information

NPI: 1881229110
Provider Name (Legal Business Name): VANESSA RUBI YETERIAN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/06/2020
Last Update Date: 09/21/2022
Certification Date: 09/21/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4500 E PACIFIC COAST HWY STE 100
LONG BEACH CA
90804-3233
US

IV. Provider business mailing address

4500 E PACIFIC COAST HWY STE 100
LONG BEACH CA
90804-3233
US

V. Phone/Fax

Practice location:
  • Phone: 562-344-1140
  • Fax:
Mailing address:
  • Phone: 562-344-1140
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number108395
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License NumberAMFT108395
License Number StateCA
# 3
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: