Provider Demographics
NPI:1013644418
Name:VASQUEZ, ESTEFANY MARIA
Entity type:Individual
Prefix:MRS
First Name:ESTEFANY
Middle Name:MARIA
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 1:14243 SW 166TH TER
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33177-1826
Mailing Address - Country:US
Mailing Address - Phone:786-627-9615
Mailing Address - Fax:
Practice Address - Street 1:5050 NW 74TH AVE STE 107
Practice Address - Street 2:
Practice Address - City:DORAL
Practice Address - State:FL
Practice Address - Zip Code:33166-5509
Practice Address - Country:US
Practice Address - Phone:305-640-8280
Practice Address - Fax:305-640-8284
Is Sole Proprietor?:Yes
Enumeration Date:2022-08-04
Last Update Date:2022-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL22-223540106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician