Healthcare Provider Details

I. General information

NPI: 1720693484
Provider Name (Legal Business Name): VANESSA PROSPER PSYD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/10/2020
Last Update Date: 05/29/2026
Certification Date: 05/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9709 3RD AVE NE
SEATTLE WA
98115-2062
US

IV. Provider business mailing address

7600 EVERGREEN WAY
EVERETT WA
98203-6421
US

V. Phone/Fax

Practice location:
  • Phone: 206-329-1760
  • Fax:
Mailing address:
  • Phone: 206-860-5414
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPY.70019774
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: