Provider Demographics
NPI:1083271647
Name:VASQUEZ, ERICK
Entity Type:Individual
Prefix:
First Name:ERICK
Middle Name:
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 1:500 FAIRWAY DRIVE, SUITE 102
Mailing Address - Street 2:
Mailing Address - City:DEERFIELD BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33441
Mailing Address - Country:US
Mailing Address - Phone:877-418-2978
Mailing Address - Fax:866-500-2186
Practice Address - Street 1:5325 N. FRESNO ST, SUITE 106
Practice Address - Street 2:
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93710
Practice Address - Country:US
Practice Address - Phone:559-740-3645
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-05-20
Last Update Date:2021-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician