Provider Demographics
NPI:1053850750
Name:VAZQUEZ, CARLOS JORGE JR (CADC-II, QMHA, CRM)
Entity Type:Individual
Prefix:
First Name:CARLOS
Middle Name:JORGE
Last Name:VAZQUEZ
Suffix:JR
Gender:M
Credentials:CADC-II, QMHA, CRM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3800 SW CEDAR HILLS BLVD STE 170
Mailing Address - Street 2:
Mailing Address - City:BEAVERTON
Mailing Address - State:OR
Mailing Address - Zip Code:97005-2020
Mailing Address - Country:US
Mailing Address - Phone:503-626-1800
Mailing Address - Fax:
Practice Address - Street 1:3800 SW CEDAR HILLS BLVD STE 170
Practice Address - Street 2:
Practice Address - City:BEAVERTON
Practice Address - State:OR
Practice Address - Zip Code:97005-2020
Practice Address - Country:US
Practice Address - Phone:503-626-1800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-02-15
Last Update Date:2024-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR23-QMHA-I-004029101YM0800X
ORTG-22-092101Y00000X
OR23-CGRM-020175T00000X
OR21-CRM-704175T00000X
OR23-06-20284101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
No175T00000XOther Service ProvidersPeer Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR23-CGRM-020OtherMHACBO CGRM
OR21-CRM-704OtherMHACBO CRM
OR23-06-20284OtherMHACBO CADC-II
OR23-QMHA-I-004029OtherMHACBO QMHA
ORTG-22-092OtherMHACBO CGAC
OR500732064Medicaid