Healthcare Provider Details

I. General information

NPI: 1528559432
Provider Name (Legal Business Name): VANESSA DYSIN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/25/2018
Last Update Date: 05/25/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2821 CROW CANYON RD STE 101
SAN RAMON CA
94583-1659
US

IV. Provider business mailing address

1717 MYRTLE ST APT B
OAKLAND CA
94607-3356
US

V. Phone/Fax

Practice location:
  • Phone: 510-999-4410
  • Fax:
Mailing address:
  • Phone: 510-274-8292
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: