Provider Demographics
NPI:1306622394
Name:SONG, VANESSA LEILANI
Entity type:Individual
Prefix:
First Name:VANESSA
Middle Name:LEILANI
Last Name:SONG
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2787 MEADOW PARK DR
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45440-1440
Mailing Address - Country:US
Mailing Address - Phone:937-329-3771
Mailing Address - Fax:
Practice Address - Street 1:1002 RAINBOW CT
Practice Address - Street 2:
Practice Address - City:FAIRBORN
Practice Address - State:OH
Practice Address - Zip Code:45324-6365
Practice Address - Country:US
Practice Address - Phone:800-824-9861
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-09-05
Last Update Date:2025-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH020686225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist