Basic Information
Provider Information
NPI: 1003296450
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: DESIR
FirstName: VANESSA
MiddleName:  
NamePrefix:  
NameSuffix:  
Credential:  
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 1355 TERRELL MILL RD SE
Address2: BLDG. 1460 SUITE 205
City: MARIETTA
State: GA
PostalCode: 300675496
CountryCode: US
TelephoneNumber: 4044399981
FaxNumber:  
Practice Location
Address1: 1355 TERRELL MILL RD SE
Address2: BLDG. 1460 SUITE 205
City: MARIETTA
State: GA
PostalCode: 300675496
CountryCode: US
TelephoneNumber: 4044399981
FaxNumber:  
Other Information
ProviderEnumerationDate: 06/01/2015
LastUpdateDate: 06/01/2015
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: F
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: Y
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  
NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
101YP2500XLPC00826GAY Behavioral Health & Social Service ProvidersCounselorProfessional

No ID Information.


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