Provider Demographics
NPI:1437692316
Name:VASQUEZ, LETICIA ANN
Entity Type:Individual
Prefix:MISS
First Name:LETICIA
Middle Name:ANN
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 1:3751 MOTOR AVE
Mailing Address - Street 2:PO BOX 34764
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90034-9998
Mailing Address - Country:US
Mailing Address - Phone:361-212-8247
Mailing Address - Fax:
Practice Address - Street 1:3544 JASMINE AVE APT 9
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90034-3831
Practice Address - Country:US
Practice Address - Phone:361-212-8247
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-11-28
Last Update Date:2020-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA966521041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAY3199728OtherDEPARTMENT OF MOTOR VEHICLES (DMV)