Healthcare Provider Details

I. General information

NPI: 1205246139
Provider Name (Legal Business Name): VANESSA DURAN LCSW, BCD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: VANESSA RAULSTON LCSW, BCD

II. Dates (important events)

Enumeration Date: 04/30/2014
Last Update Date: 10/22/2022
Certification Date: 10/22/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

209 JOURNEYS END
VISTA CA
92083-7680
US

IV. Provider business mailing address

34800 BOB WILSON DR
SAN DIEGO CA
92134-1098
US

V. Phone/Fax

Practice location:
  • Phone: 760-622-4739
  • Fax:
Mailing address:
  • Phone: 619-532-7150
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number009408
License Number StateCT
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: