Provider Demographics
NPI:1205362365
Name:VASQUEZ, BRYAN (CATC III)
Entity Type:Individual
Prefix:
First Name:BRYAN
Middle Name:
Last Name:VASQUEZ
Suffix:
Gender:M
Credentials:CATC III
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4540 CAMPUS DR
Mailing Address - Street 2:SUITE #113
Mailing Address - City:NEWPORT BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92660
Mailing Address - Country:US
Mailing Address - Phone:714-800-3199
Mailing Address - Fax:
Practice Address - Street 1:4540 CAMPUS DR
Practice Address - Street 2:SUITE #113
Practice Address - City:NEWPORT BEACH
Practice Address - State:CA
Practice Address - Zip Code:92660
Practice Address - Country:US
Practice Address - Phone:714-800-3199
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-05-11
Last Update Date:2020-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1911397-III101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Single Specialty