Provider Demographics
NPI:1043485923
Name:VASQUEZ, MICHAEL BERNARD
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:BERNARD
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 1:1424 HUMBUG CREEK DR
Mailing Address - Street 2:
Mailing Address - City:FOLSOM
Mailing Address - State:CA
Mailing Address - Zip Code:95630-7641
Mailing Address - Country:US
Mailing Address - Phone:916-985-8610
Mailing Address - Fax:
Practice Address - Street 1:100 PRISON RD
Practice Address - Street 2:
Practice Address - City:REPRESA
Practice Address - State:CA
Practice Address - Zip Code:95671-3000
Practice Address - Country:US
Practice Address - Phone:916-985-8610
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-04-23
Last Update Date:2008-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA15750103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical