Healthcare Provider Details

I. General information

NPI: 1396494084
Provider Name (Legal Business Name): VANESSA LYNN GAVINO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/21/2022
Last Update Date: 06/24/2026
Certification Date: 06/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1116 14TH AVE
LONGVIEW WA
98632-3017
US

IV. Provider business mailing address

1116 14TH AVE
LONGVIEW WA
98632-3017
US

V. Phone/Fax

Practice location:
  • Phone: 360-261-6930
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License Number
License Number StateWA
# 2
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: