Provider Demographics
NPI:1790079150
Name:VASQUEZ, CONNIE LOUISE (CAC II (UPDATE))
Entity Type:Individual
Prefix:MRS
First Name:CONNIE
Middle Name:LOUISE
Last Name:VASQUEZ
Suffix:
Gender:F
Credentials:CAC II (UPDATE)
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:509 E 13TH ST
Mailing Address - Street 2:
Mailing Address - City:PUEBLO
Mailing Address - State:CO
Mailing Address - Zip Code:81001-2940
Mailing Address - Country:US
Mailing Address - Phone:719-546-6666
Mailing Address - Fax:719-543-7764
Practice Address - Street 1:509 E 13TH ST
Practice Address - Street 2:
Practice Address - City:PUEBLO
Practice Address - State:CO
Practice Address - Zip Code:81001-2940
Practice Address - Country:US
Practice Address - Phone:719-546-6666
Practice Address - Fax:719-543-7764
Is Sole Proprietor?:No
Enumeration Date:2011-06-02
Last Update Date:2011-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO4891101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)