Provider Demographics
NPI:1275981326
Name:VASQUEZ, CARLA MARIE
Entity Type:Individual
Prefix:MS
First Name:CARLA
Middle Name:MARIE
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 1:901 N. PACIFIC COAST HIGHWAY
Mailing Address - Street 2:200A
Mailing Address - City:REDONDO BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90277
Mailing Address - Country:US
Mailing Address - Phone:310-316-1610
Mailing Address - Fax:
Practice Address - Street 1:901 N. PACIFIC COAST HIGHWAY
Practice Address - Street 2:200A
Practice Address - City:REDONDO BEACH
Practice Address - State:CA
Practice Address - Zip Code:90277
Practice Address - Country:US
Practice Address - Phone:310-316-1610
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-05-31
Last Update Date:2016-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA92742106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist