MEDICARE: VANESSA ANNWANETT KANISTANAUX

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YA0400X	Addiction (Substance Use Disorder) Counselor

General Provider Information

NPI Number	:	1770766594
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	VANESSA ANNWANETT KANISTANAUX

Provider Business Mailing Address
First Line	:	1045 N GARFIELD AVE
Second Line	:
City	:	PASADENA
State	:	CA
Zip	:	91104-3533
Country	:	US
Telephone Number	:	626-533-1804
Fax Number	:

Provider Business Practice Location Address
First Line	:	1460 N LAKE AVE
Second Line	:	SUITE 107
City	:	PASADENA
State	:	CA
Zip	:	91104-2300
Country	:	US
Telephone Number	:	626-398-3796
Fax Number	:	626-398-3895

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/14/2007
Last Update Date	:	12/14/2007

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Directions to “ VANESSA ANNWANETT KANISTANAUX ” Practice Location

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