Provider Demographics
NPI:1730067752
Name:BASULTO MACIAS, VANESSA
Entity type:Individual
Prefix:
First Name:VANESSA
Middle Name:
Last Name:BASULTO MACIAS
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 1:1839 S EL DORADO ST
Mailing Address - Street 2:
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95206-2025
Mailing Address - Country:US
Mailing Address - Phone:209-463-0872
Mailing Address - Fax:
Practice Address - Street 1:1839 S EL DORADO ST
Practice Address - Street 2:
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95206-2025
Practice Address - Country:US
Practice Address - Phone:209-463-0872
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-08-26
Last Update Date:2025-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)