Provider Demographics
NPI:1083166789
Name:CHAN VASQUEZ, VILMA
Entity Type:Individual
Prefix:
First Name:VILMA
Middle Name:
Last Name:CHAN 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 1:192 STONEWAY DR NW
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97304-4517
Mailing Address - Country:US
Mailing Address - Phone:503-991-9165
Mailing Address - Fax:503-566-2977
Practice Address - Street 1:300 DOUGLAS AVE NE
Practice Address - Street 2:
Practice Address - City:GERVAIS
Practice Address - State:OR
Practice Address - Zip Code:97026-4517
Practice Address - Country:US
Practice Address - Phone:503-991-9165
Practice Address - Fax:503-566-2977
Is Sole Proprietor?:No
Enumeration Date:2016-10-28
Last Update Date:2016-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health