Provider Demographics
NPI:1639150329
Name:VASQUEZ, VANESSA
Entity Type:Individual
Prefix:
First Name:VANESSA
Middle Name:
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 1:10507 WILLOWBRAE DR
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33624-5223
Mailing Address - Country:US
Mailing Address - Phone:630-698-3528
Mailing Address - Fax:
Practice Address - Street 1:13101 BRUCE B DOWNS BLVD
Practice Address - Street 2:USF EARLY STEPS
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33612-3803
Practice Address - Country:US
Practice Address - Phone:813-974-7938
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-11-09
Last Update Date:2017-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT234312251P0200X
222Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251P0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistPediatrics
No222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLPT23431OtherFLORIDA LICENSE
VAD000Medicare UPIN