Provider Demographics
NPI:1912175191
Name:VIGILANTE, VANESSA A (PHD)
Entity type:Individual
Prefix:
First Name:VANESSA
Middle Name:A
Last Name:VIGILANTE
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:400 FOULK RD APT 4C6
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:DE
Mailing Address - Zip Code:19803-3826
Mailing Address - Country:US
Mailing Address - Phone:302-272-5508
Mailing Address - Fax:
Practice Address - Street 1:400 FOULK RD APT 4C6
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:DE
Practice Address - Zip Code:19803-3826
Practice Address - Country:US
Practice Address - Phone:302-272-5508
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-02-11
Last Update Date:2024-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPS016365103T00000X, 103TC2200X
DEB10000809103TC2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent
No103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0200786Medicaid