Provider Demographics
NPI:1427705060
Name:DE LA TORRE, VANESSA
Entity type:Individual
Prefix:
First Name:VANESSA
Middle Name:
Last Name:DE LA TORRE
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 1:31500 GRAPE ST STE 3-191
Mailing Address - Street 2:
Mailing Address - City:LAKE ELSINORE
Mailing Address - State:CA
Mailing Address - Zip Code:92532-9709
Mailing Address - Country:US
Mailing Address - Phone:951-445-3645
Mailing Address - Fax:
Practice Address - Street 1:3924 RIVERVIEW DR
Practice Address - Street 2:
Practice Address - City:JURUPA VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92509-6611
Practice Address - Country:US
Practice Address - Phone:951-445-3645
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-03-03
Last Update Date:2024-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
CAMPSS-AYFPQS175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health