Provider Demographics
NPI:1851774699
Name:VASQUEZ, EVELYN (BS, MS)
Entity Type:Individual
Prefix:
First Name:EVELYN
Middle Name:
Last Name:VASQUEZ
Suffix:
Gender:F
Credentials:BS, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10818 POBLADO RD
Mailing Address - Street 2:APT 732
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92127-5319
Mailing Address - Country:US
Mailing Address - Phone:909-957-2407
Mailing Address - Fax:
Practice Address - Street 1:545 LAUREL ST
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92101-1634
Practice Address - Country:US
Practice Address - Phone:619-233-4399
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-06-29
Last Update Date:2017-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA101YM0800X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program