Provider Demographics
NPI:1710663034
Name:VAZQUEZ, BRIAN
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:
Last Name:VAZQUEZ
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1801 W OLYMPIC BLVD # 2265
Mailing Address - Street 2:
Mailing Address - City:PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91199-0001
Mailing Address - Country:US
Mailing Address - Phone:702-777-4809
Mailing Address - Fax:702-777-4818
Practice Address - Street 1:874 AMERICAN PACIFIC DR
Practice Address - Street 2:
Practice Address - City:HENDERSON
Practice Address - State:NV
Practice Address - Zip Code:89014-8800
Practice Address - Country:US
Practice Address - Phone:702-777-4808
Practice Address - Fax:702-777-4822
Is Sole Proprietor?:Yes
Enumeration Date:2023-06-22
Last Update Date:2023-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVRBT2553106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician