Provider Demographics
NPI:1003358003
Name:VASQUEZ, WELLINGTON ENRIQUE
Entity Type:Individual
Prefix:
First Name:WELLINGTON
Middle Name:ENRIQUE
Last Name:VASQUEZ
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9577 SW 41ST ST
Mailing Address - Street 2:APT. # 108
Mailing Address - City:MIRAMAR
Mailing Address - State:FL
Mailing Address - Zip Code:33025-7347
Mailing Address - Country:US
Mailing Address - Phone:786-315-7915
Mailing Address - Fax:
Practice Address - Street 1:9577 SW 41ST ST
Practice Address - Street 2:APT. # 108
Practice Address - City:MIRAMAR
Practice Address - State:FL
Practice Address - Zip Code:33025-7347
Practice Address - Country:US
Practice Address - Phone:786-315-7915
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-11-08
Last Update Date:2016-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-16-22972106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLRBT-16-22972OtherBEHAVIOR ANALYST CERTIFICATION BOARD