Healthcare Provider Details

I. General information

NPI: 1568105948
Provider Name (Legal Business Name): VANESSA CORTEZ
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/14/2022
Last Update Date: 08/25/2025
Certification Date: 08/25/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

121 W MAIN ST
PORT WASHINGTON WI
53074-1813
US

IV. Provider business mailing address

502 MAIN ST
KEWASKUM WI
53040-9792
US

V. Phone/Fax

Practice location:
  • Phone: 262-284-8157
  • Fax:
Mailing address:
  • Phone: 708-712-3592
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number8541-226
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number8541-226
License Number StateWI
# 3
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number8541-226
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: