Healthcare Provider Details

I. General information

NPI: 1154698793
Provider Name (Legal Business Name): VINEESHA RATHNAM
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/28/2011
Last Update Date: 11/28/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1022 E MAIN ST
BENTON HARBOR MI
49022-3036
US

IV. Provider business mailing address

3349 PLEASANT ST
BERRIEN SPRINGS MI
49103-9519
US

V. Phone/Fax

Practice location:
  • Phone: 269-926-0015
  • Fax: 269-926-0123
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: