Provider Demographics
NPI:1023513777
Name:VASQUEZ, NOHEMI
Entity type:Individual
Prefix:
First Name:NOHEMI
Middle Name:
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 1:139 RIVER VISTA PL STE 201
Mailing Address - Street 2:
Mailing Address - City:TWIN FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83301-3060
Mailing Address - Country:US
Mailing Address - Phone:208-858-5175
Mailing Address - Fax:
Practice Address - Street 1:139 RIVER VISTA PL STE 201
Practice Address - Street 2:
Practice Address - City:TWIN FALLS
Practice Address - State:ID
Practice Address - Zip Code:83301-3060
Practice Address - Country:US
Practice Address - Phone:208-858-5175
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-03-26
Last Update Date:2023-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDCOUI-6786101YM0800X
IDLPC-8261101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID15729334OtherCAQH