Provider Demographics
NPI:1184400194
Name:VAZQUEZ, GISELLE IVETTE
Entity type:Individual
Prefix:
First Name:GISELLE
Middle Name:IVETTE
Last Name:VAZQUEZ
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 1:3801 E WYATT EARP AVE
Mailing Address - Street 2:
Mailing Address - City:EAGLE MOUNTAIN
Mailing Address - State:UT
Mailing Address - Zip Code:84005-4499
Mailing Address - Country:US
Mailing Address - Phone:801-651-8808
Mailing Address - Fax:
Practice Address - Street 1:881 W BAXTER DR STE 100
Practice Address - Street 2:
Practice Address - City:SOUTH JORDAN
Practice Address - State:UT
Practice Address - Zip Code:84095-8506
Practice Address - Country:US
Practice Address - Phone:877-511-6823
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-09-05
Last Update Date:2023-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician