Provider Demographics
NPI:1255841953
Name:VAZQUEZ, COURTNEY (LAC, LMT)
Entity type:Individual
Prefix:
First Name:COURTNEY
Middle Name:
Last Name:VAZQUEZ
Suffix:
Gender:F
Credentials:LAC, LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:712 CAULDWELL AVE
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10455-1531
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:712 CAULDWELL AVE
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10455-1531
Practice Address - Country:US
Practice Address - Phone:718-844-1719
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-10-07
Last Update Date:2017-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY027581-1225700000X
NY005944-1171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist
No225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist