Healthcare Provider Details

I. General information

NPI: 1760190128
Provider Name (Legal Business Name): VANESSA LYNN CHASE LMHC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/14/2022
Last Update Date: 11/14/2022
Certification Date: 11/02/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

602 S WASHINGTON AVE
FREDERICKSBURG IA
50630-1003
US

IV. Provider business mailing address

PO BOX 206
FREDERICKSBURG IA
50630-0206
US

V. Phone/Fax

Practice location:
  • Phone: 563-237-5300
  • Fax: 563-237-5304
Mailing address:
  • Phone: 563-237-5300
  • Fax: 563-237-5304

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number099562
License Number StateIA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: