Provider Demographics
NPI:1255753901
Name:VASQUEZ GONZALEZ, SHANNON
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:
Last Name:VASQUEZ GONZALEZ
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 1:155 WILLOWBROOK DR
Mailing Address - Street 2:
Mailing Address - City:BEN LOMOND
Mailing Address - State:CA
Mailing Address - Zip Code:95005-9714
Mailing Address - Country:US
Mailing Address - Phone:831-663-5199
Mailing Address - Fax:831-336-1033
Practice Address - Street 1:155 WILLOWBROOK DR
Practice Address - Street 2:
Practice Address - City:BEN LOMOND
Practice Address - State:CA
Practice Address - Zip Code:95005-9714
Practice Address - Country:US
Practice Address - Phone:831-663-5199
Practice Address - Fax:831-336-1033
Is Sole Proprietor?:No
Enumeration Date:2014-01-15
Last Update Date:2014-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health