Provider Demographics
NPI:1053001768
Name:VAZQUEZ CAMACHO, EDWIN I (CSW)
Entity type:Individual
Prefix:
First Name:EDWIN
Middle Name:I
Last Name:VAZQUEZ CAMACHO
Suffix:
Gender:M
Credentials:CSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:URB. ESTANCIAS DE SANTA ISABEL
Mailing Address - Street 2:115 CALLE AMATISTA
Mailing Address - City:SANTA ISABEL
Mailing Address - State:PR
Mailing Address - Zip Code:00757-0000
Mailing Address - Country:US
Mailing Address - Phone:787-579-4370
Mailing Address - Fax:
Practice Address - Street 1:EDIFICIO PROFESIONAL DE SANTA ISABEL SUITE 101
Practice Address - Street 2:CARR 153 KM 7.5 BARRIO USERAS
Practice Address - City:SANTA ISABEL
Practice Address - State:PR
Practice Address - Zip Code:00757-0000
Practice Address - Country:US
Practice Address - Phone:787-579-4370
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-05-08
Last Update Date:2024-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR163611041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR039599700Medicaid