Provider Demographics
NPI:1831827526
Name:VIZCAINO, ANDREA (SUDPT)
Entity type:Individual
Prefix:
First Name:ANDREA
Middle Name:
Last Name:VIZCAINO
Suffix:
Gender:F
Credentials:SUDPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2204 NE 140TH ST
Mailing Address - Street 2:
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98686-3020
Mailing Address - Country:US
Mailing Address - Phone:360-721-9191
Mailing Address - Fax:
Practice Address - Street 1:2924 FALK RD
Practice Address - Street 2:
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98661-5604
Practice Address - Country:US
Practice Address - Phone:360-690-3069
Practice Address - Fax:360-726-5961
Is Sole Proprietor?:Yes
Enumeration Date:2022-08-10
Last Update Date:2022-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACO61326935101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)