Provider Demographics
NPI:1053953448
Name:VASQUEZ, CLARA SUSEL
Entity type:Individual
Prefix:
First Name:CLARA
Middle Name:SUSEL
Last Name:VASQUEZ
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 1:6905 W 7TH AVE APT 208
Mailing Address - Street 2:
Mailing Address - City:HIALEAH
Mailing Address - State:FL
Mailing Address - Zip Code:33014-4817
Mailing Address - Country:US
Mailing Address - Phone:305-896-8161
Mailing Address - Fax:
Practice Address - Street 1:6905 W 7TH AVE APT 208
Practice Address - Street 2:
Practice Address - City:HIALEAH
Practice Address - State:FL
Practice Address - Zip Code:33014-4817
Practice Address - Country:US
Practice Address - Phone:305-896-8161
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-10-17
Last Update Date:2022-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106S00000X
FLBCBA-1-21-56430103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician