Provider Demographics
NPI:1487144275
Name:HAACK, VINESSA JO (BCBA)
Entity type:Individual
Prefix:
First Name:VINESSA
Middle Name:JO
Last Name:HAACK
Suffix:
Gender:F
Credentials:BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1301 BURRWOOD ST
Mailing Address - Street 2:
Mailing Address - City:TEMPERANCE
Mailing Address - State:MI
Mailing Address - Zip Code:48182-1234
Mailing Address - Country:US
Mailing Address - Phone:734-652-8402
Mailing Address - Fax:
Practice Address - Street 1:15384 S DIXIE HWY
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:MI
Practice Address - Zip Code:48161-3773
Practice Address - Country:US
Practice Address - Phone:734-652-8402
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-16
Last Update Date:2022-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
103K00000X, 106S00000X
17-45464106S00000X
MI7401001810103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Single Specialty
No106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Single Specialty