Provider Demographics
NPI:1689405490
Name:VAZQUEZ, VANESSA ILIANA
Entity type:Individual
Prefix:MISS
First Name:VANESSA
Middle Name:ILIANA
Last Name: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 1:801 CORPORATE CENTER DR STE 210
Mailing Address - Street 2:
Mailing Address - City:POMONA
Mailing Address - State:CA
Mailing Address - Zip Code:91768-2627
Mailing Address - Country:US
Mailing Address - Phone:909-618-0974
Mailing Address - Fax:
Practice Address - Street 1:801 CORPORATE CENTER DR
Practice Address - Street 2:STE 210
Practice Address - City:POMONA
Practice Address - State:CA
Practice Address - Zip Code:91768
Practice Address - Country:US
Practice Address - Phone:909-618-0974
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-08-13
Last Update Date:2024-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CABCBA103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst