Healthcare Provider Details

I. General information

NPI: 1639621022
Provider Name (Legal Business Name): VANESSA IACOVELLI
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/01/2016
Last Update Date: 11/01/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6767 S SPRUCE ST STE 100
CENTENNIAL CO
80112-6118
US

IV. Provider business mailing address

4622 S PAGOSA CIR
AURORA CO
80015-1950
US

V. Phone/Fax

Practice location:
  • Phone: 303-225-7673
  • Fax:
Mailing address:
  • Phone: 562-569-8639
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number10-215-0970
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: