Provider Demographics
NPI:1467572479
Name:VASQUEZ, MARY JO PUGLISI (PHD)
Entity Type:Individual
Prefix:
First Name:MARY JO
Middle Name:PUGLISI
Last Name:VASQUEZ
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:DR
Other - First Name:MARYJO
Other - Middle Name:
Other - Last Name:VASQUEZ
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PHD
Mailing Address - Street 1:2335 BLACK ROCK TPKE
Mailing Address - Street 2:HALL #2
Mailing Address - City:FAIRFIELD
Mailing Address - State:CT
Mailing Address - Zip Code:06825-3220
Mailing Address - Country:US
Mailing Address - Phone:203-816-0183
Mailing Address - Fax:
Practice Address - Street 1:2335 BLACK ROCK TPKE
Practice Address - Street 2:HALL #2
Practice Address - City:FAIRFIELD
Practice Address - State:CT
Practice Address - Zip Code:06825-3220
Practice Address - Country:US
Practice Address - Phone:203-816-0183
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-31
Last Update Date:2014-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0167682084P0805X
CT3188103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No2084P0805XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyGeriatric Psychiatry