Provider Demographics
NPI:1649943119
Name:PETRONIO-VAZQUEZ, CYNTHIA
Entity type:Individual
Prefix:MRS
First Name:CYNTHIA
Middle Name:
Last Name:PETRONIO-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 1:89 VALENTINE ST
Mailing Address - Street 2:
Mailing Address - City:NEWINGTON
Mailing Address - State:CT
Mailing Address - Zip Code:06111-3844
Mailing Address - Country:US
Mailing Address - Phone:860-372-2278
Mailing Address - Fax:
Practice Address - Street 1:791 S MAIN ST
Practice Address - Street 2:
Practice Address - City:PLANTSVILLE
Practice Address - State:CT
Practice Address - Zip Code:06479-1519
Practice Address - Country:US
Practice Address - Phone:860-378-8090
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-29
Last Update Date:2021-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT1898101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty