Provider Demographics
NPI:1194187625
Name:VAZQUEZ, MIZRAIN (CADC I)
Entity Type:Individual
Prefix:
First Name:MIZRAIN
Middle Name:
Last Name:VAZQUEZ
Suffix:
Gender:M
Credentials:CADC I
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:510 NW 4TH ST
Mailing Address - Street 2:
Mailing Address - City:GRANTS PASS
Mailing Address - State:OR
Mailing Address - Zip Code:97526-2078
Mailing Address - Country:US
Mailing Address - Phone:541-474-5196
Mailing Address - Fax:541-474-5172
Practice Address - Street 1:510 NW 4TH ST
Practice Address - Street 2:
Practice Address - City:GRANTS PASS
Practice Address - State:OR
Practice Address - Zip Code:97526-2078
Practice Address - Country:US
Practice Address - Phone:541-474-5196
Practice Address - Fax:541-474-5172
Is Sole Proprietor?:No
Enumeration Date:2016-03-23
Last Update Date:2016-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR13-12-43101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)