Provider Demographics
NPI:1942563523
Name:MEZQUITA, VASTI EUNICE (BACHELOR)
Entity Type:Individual
Prefix:
First Name:VASTI
Middle Name:EUNICE
Last Name:MEZQUITA
Suffix:
Gender:F
Credentials:BACHELOR
Other - Prefix:
Other - First Name:VASTI
Other - Middle Name:EUNICE
Other - Last Name:AYALA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:5058 ARROYO LN APT I-305
Mailing Address - Street 2:
Mailing Address - City:SIMI VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:93063-7632
Mailing Address - Country:US
Mailing Address - Phone:805-791-0052
Mailing Address - Fax:
Practice Address - Street 1:13130 BURBANK BLVD
Practice Address - Street 2:
Practice Address - City:SHERMAN OAKS
Practice Address - State:CA
Practice Address - Zip Code:91401
Practice Address - Country:US
Practice Address - Phone:818-779-5190
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-19
Last Update Date:2012-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA251S00000X251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health