Provider Demographics
NPI:1902409469
Name:VAZQUEZ, MARIENELLY (LCSW)
Entity Type:Individual
Prefix:
First Name:MARIENELLY
Middle Name:
Last Name:VAZQUEZ
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 1:20 KOSTA ST APT 3
Mailing Address - Street 2:
Mailing Address - City:WORCESTER
Mailing Address - State:MA
Mailing Address - Zip Code:01607-1968
Mailing Address - Country:US
Mailing Address - Phone:508-414-7471
Mailing Address - Fax:
Practice Address - Street 1:222 MAPLE AVE
Practice Address - Street 2:
Practice Address - City:SHREWSBURY
Practice Address - State:MA
Practice Address - Zip Code:01545-2732
Practice Address - Country:US
Practice Address - Phone:508-845-6932
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-11-18
Last Update Date:2020-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA9048891041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA1902409469Medicaid