Provider Demographics
NPI:1164940359
Name:VASQUEZ, STEPHANIE MARLENE
Entity Type:Individual
Prefix:MISS
First Name:STEPHANIE
Middle Name:MARLENE
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 1:4110 RANDALL PKWY UNIT 1F
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:28403-2812
Mailing Address - Country:US
Mailing Address - Phone:571-426-1121
Mailing Address - Fax:
Practice Address - Street 1:705 S KERR AVE
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:NC
Practice Address - Zip Code:28403-8425
Practice Address - Country:US
Practice Address - Phone:910-782-3499
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-09-07
Last Update Date:2017-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician