Provider Demographics
NPI:1649662214
Name:VAZQUEZ-NORMAN, GREGORY (LISW-S)
Entity type:Individual
Prefix:
First Name:GREGORY
Middle Name:
Last Name:VAZQUEZ-NORMAN
Suffix:
Gender:M
Credentials:LISW-S
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:195 N GRANT AVE
Mailing Address - Street 2:SUITE 205
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43215-2855
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:22001 FAIRMOUNT BLVD
Practice Address - Street 2:
Practice Address - City:SHAKER HEIGHTS
Practice Address - State:OH
Practice Address - Zip Code:44118
Practice Address - Country:US
Practice Address - Phone:216-320-6699
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-02-19
Last Update Date:2018-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHI.1451118-SUPV1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0197473Medicaid