Provider Demographics
NPI:1043705403
Name:VASQUEZ, CAROLYN LOUISE
Entity Type:Individual
Prefix:
First Name:CAROLYN
Middle Name:LOUISE
Last Name:VASQUEZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:658 SW MCCROHAN ST
Mailing Address - Street 2:
Mailing Address - City:OAK HARBOR
Mailing Address - State:WA
Mailing Address - Zip Code:98277-4511
Mailing Address - Country:US
Mailing Address - Phone:360-929-6622
Mailing Address - Fax:
Practice Address - Street 1:31955 HIGHWAY 20
Practice Address - Street 2:
Practice Address - City:OAK HARBOR
Practice Address - State:WA
Practice Address - Zip Code:98277-5211
Practice Address - Country:US
Practice Address - Phone:360-279-9000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-06-28
Last Update Date:2018-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician