Provider Demographics
NPI:1952040404
Name:VASQUEZ, MARILYN E
Entity Type:Individual
Prefix:
First Name:MARILYN
Middle Name:E
Last Name:VASQUEZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11726 LEMAY ST APT 13
Mailing Address - Street 2:
Mailing Address - City:NORTH HOLLYWOOD
Mailing Address - State:CA
Mailing Address - Zip Code:91606-1639
Mailing Address - Country:US
Mailing Address - Phone:747-218-9229
Mailing Address - Fax:
Practice Address - Street 1:5455 WILSHIRE BLVD STE 800
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90036-4271
Practice Address - Country:US
Practice Address - Phone:833-669-4222
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-06-02
Last Update Date:2022-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARBT-22-203215106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician