Provider Demographics
NPI:1821143181
Name:VASQUEZ, TERRI LYNN (LCSW)
Entity Type:Individual
Prefix:
First Name:TERRI
Middle Name:LYNN
Last Name:VASQUEZ
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1817 E 10TH ST
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85709-0001
Mailing Address - Country:US
Mailing Address - Phone:520-904-1585
Mailing Address - Fax:520-903-9113
Practice Address - Street 1:350 N WILMOT RD
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85711-2602
Practice Address - Country:US
Practice Address - Phone:520-873-3000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLISAC-10749101YA0400X
AZLCSW-11013104100000X, 1041C0700X, 1041S0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Not Answered104100000XBehavioral Health & Social Service ProvidersSocial Worker
Not Answered1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Not Answered1041S0200XBehavioral Health & Social Service ProvidersSocial WorkerSchool
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ861080Medicaid
AZZ83788Medicare ID - Type Unspecified