Provider Demographics
NPI:1265069165
Name:VAZQUEZ, ANDRES (MS)
Entity type:Individual
Prefix:
First Name:ANDRES
Middle Name:
Last Name:VAZQUEZ
Suffix:
Gender:M
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9340 LAKE CHASE ISLAND WAY
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33626-1932
Mailing Address - Country:US
Mailing Address - Phone:813-458-8831
Mailing Address - Fax:
Practice Address - Street 1:5745 MAIN ST
Practice Address - Street 2:
Practice Address - City:NEW PORT RICHEY
Practice Address - State:FL
Practice Address - Zip Code:34652-2737
Practice Address - Country:US
Practice Address - Phone:813-458-8831
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-03-23
Last Update Date:2020-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLIMH19338101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty