Provider Demographics
NPI:1619075249
Name:BADILLO, BERENICE VAZQUEZ (MA, LMFT ATR)
Entity Type:Individual
Prefix:MISS
First Name:BERENICE
Middle Name:VAZQUEZ
Last Name:BADILLO
Suffix:
Gender:F
Credentials:MA, LMFT ATR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2250 FOURTH AVE STE 301
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92101-2124
Mailing Address - Country:US
Mailing Address - Phone:619-525-9903
Mailing Address - Fax:619-525-9908
Practice Address - Street 1:2250 FOURTH AVE STE 301
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92101-2124
Practice Address - Country:US
Practice Address - Phone:619-525-9903
Practice Address - Fax:619-525-9908
Is Sole Proprietor?:No
Enumeration Date:2006-09-20
Last Update Date:2011-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA49631106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA9823Medicare ID - Type UnspecifiedMEDI-CAL PROVIDER NUMBER