Healthcare Provider Details

I. General information

NPI: 1982182846
Provider Name (Legal Business Name): VANESSA BROOKE LIGHTFOOT MSW LSWAIC SUDP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/02/2018
Last Update Date: 08/17/2026
Certification Date: 08/17/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1520 KELLY PL
WALLA WALLA WA
99362-8607
US

IV. Provider business mailing address

1520 KELLY PL
WALLA WALLA WA
99362-8607
US

V. Phone/Fax

Practice location:
  • Phone: 509-524-2920
  • Fax:
Mailing address:
  • Phone: 509-524-2920
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberSWIA.SC.70097573
License Number StateWA
# 2
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberCG6083778
License Number StateWA
# 3
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number6082656
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: