Healthcare Provider Details

I. General information

NPI: 1740271261
Provider Name (Legal Business Name): VIVIAN ANNETT VANESSEN LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: X

Provider Other Name: MISS VIVIAN ANNETT MOODY

II. Dates (important events)

Enumeration Date: 11/03/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1028 WALNUT ST LEWIS & CLARK BHS
YANKTON SD
57078-2910
US

IV. Provider business mailing address

1028 WALNUT ST
YANKTON SD
57078-2910
US

V. Phone/Fax

Practice location:
  • Phone: 605-665-4606
  • Fax: 605-665-4673
Mailing address:
  • Phone: 605-665-4606
  • Fax: 605-665-4673

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License NumberLPC643
License Number StateSD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: