Provider Demographics
NPI:1710677356
Name:VASQUEZ, KELLIE MARIE (MSW)
Entity Type:Individual
Prefix:
First Name:KELLIE
Middle Name:MARIE
Last Name:VASQUEZ
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3355 N WHITE AVENUE
Mailing Address - Street 2:PO BOX #713
Mailing Address - City:LA VERNE
Mailing Address - State:CA
Mailing Address - Zip Code:91750
Mailing Address - Country:US
Mailing Address - Phone:626-244-7748
Mailing Address - Fax:
Practice Address - Street 1:2275 S MAIN ST STE 201
Practice Address - Street 2:
Practice Address - City:CORONA
Practice Address - State:CA
Practice Address - Zip Code:92882-5303
Practice Address - Country:US
Practice Address - Phone:951-279-3222
Practice Address - Fax:951-279-5222
Is Sole Proprietor?:No
Enumeration Date:2023-05-08
Last Update Date:2023-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical