Provider Demographics
NPI:1699140541
Name:ABBOTT, VANESSA LYNNE (LLPC)
Entity type:Individual
Prefix:
First Name:VANESSA
Middle Name:LYNNE
Last Name:ABBOTT
Suffix:
Gender:F
Credentials:LLPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2045 OLD VALLEY CT SE
Mailing Address - Street 2:
Mailing Address - City:KENTWOOD
Mailing Address - State:MI
Mailing Address - Zip Code:49508-6531
Mailing Address - Country:US
Mailing Address - Phone:616-780-6563
Mailing Address - Fax:
Practice Address - Street 1:1465 3 MILE RD NW
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49544-1614
Practice Address - Country:US
Practice Address - Phone:616-780-6563
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-12-03
Last Update Date:2015-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6401015083101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional