Provider Demographics
NPI:1093596769
Name:VAQUERA, DAMIAN
Entity Type:Individual
Prefix:
First Name:DAMIAN
Middle Name:
Last Name:VAQUERA
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 1:1650 EXPLORATION FALLS DR
Mailing Address - Street 2:
Mailing Address - City:CHULA VISTA
Mailing Address - State:CA
Mailing Address - Zip Code:91915-1961
Mailing Address - Country:US
Mailing Address - Phone:619-591-5500
Mailing Address - Fax:
Practice Address - Street 1:1650 EXPLORATION FALLS DR
Practice Address - Street 2:
Practice Address - City:CHULA VISTA
Practice Address - State:CA
Practice Address - Zip Code:91915-1961
Practice Address - Country:US
Practice Address - Phone:619-591-5500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-10-09
Last Update Date:2023-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool