Provider Demographics
NPI:1629647607
Name:VAZQUEZ, VANESSA (AMFT)
Entity Type:Individual
Prefix:
First Name:VANESSA
Middle Name:
Last Name:VAZQUEZ
Suffix:
Gender:F
Credentials:AMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10343 SAN DIEGO MISSION RD APT 216
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92108-2123
Mailing Address - Country:US
Mailing Address - Phone:619-997-0869
Mailing Address - Fax:
Practice Address - Street 1:1031 25TH ST
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92102-2102
Practice Address - Country:US
Practice Address - Phone:619-232-6454
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-23
Last Update Date:2021-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
CAAMFT128550106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program