Provider Demographics
NPI:1427675347
Name:GONZALEZ VAZQUEZ, LOURDES A
Entity type:Individual
Prefix:
First Name:LOURDES
Middle Name:A
Last Name:GONZALEZ 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:AVE. AMERICO MIRANDA 401
Mailing Address - Street 2:COOP LOS ROBLES 806-B
Mailing Address - City:SAN JUAN
Mailing Address - State:PR
Mailing Address - Zip Code:00927
Mailing Address - Country:US
Mailing Address - Phone:787-529-1802
Mailing Address - Fax:
Practice Address - Street 1:AVE. MUNOZ RIVERA 1007
Practice Address - Street 2:EDIFICIO DARLINGTON OFICINA 902
Practice Address - City:SAN JUAN
Practice Address - State:PR
Practice Address - Zip Code:00927
Practice Address - Country:US
Practice Address - Phone:787-529-1802
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-06-26
Last Update Date:2020-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR2113103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical