Provider Demographics
NPI:1619291440
Name:VAZ, ANDRE RICARDO (LCSW)
Entity Type:Individual
Prefix:
First Name:ANDRE
Middle Name:RICARDO
Last Name:VAZ
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 555191
Mailing Address - Street 2:
Mailing Address - City:CAMP PENDLETON
Mailing Address - State:CA
Mailing Address - Zip Code:92055-5191
Mailing Address - Country:US
Mailing Address - Phone:760-719-3312
Mailing Address - Fax:
Practice Address - Street 1:PO BOX 555191
Practice Address - Street 2:
Practice Address - City:CAMP PENDLETON
Practice Address - State:CA
Practice Address - Zip Code:92055-5191
Practice Address - Country:US
Practice Address - Phone:760-719-3312
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-03-23
Last Update Date:2024-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSW96761041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical