Provider Demographics
NPI:1003983248
Name:VAZQUEZ, LICED (OTR)
Entity Type:Individual
Prefix:MS
First Name:LICED
Middle Name:
Last Name:VAZQUEZ
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1350 SW 75TH AVE
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33144-4422
Mailing Address - Country:US
Mailing Address - Phone:305-300-1904
Mailing Address - Fax:
Practice Address - Street 1:1350 SW 75TH AVE
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33144-4422
Practice Address - Country:US
Practice Address - Phone:305-300-1904
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-30
Last Update Date:2013-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL10836225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLK9168Medicare ID - Type UnspecifiedPROVIDER NUMBER