Provider Demographics
NPI:1902151830
Name:VAZQUEZ, MINERVA (MA SP ED SAS)
Entity Type:Individual
Prefix:MS
First Name:MINERVA
Middle Name:
Last Name:VAZQUEZ
Suffix:
Gender:F
Credentials:MA SP ED SAS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:43-07 161 ST STREET
Mailing Address - Street 2:FLOOR 1
Mailing Address - City:FLUSHING
Mailing Address - State:NY
Mailing Address - Zip Code:11358
Mailing Address - Country:US
Mailing Address - Phone:917-379-8770
Mailing Address - Fax:
Practice Address - Street 1:43-07 161 ST STREET
Practice Address - Street 2:FLOOR 1
Practice Address - City:FLUSHING
Practice Address - State:NY
Practice Address - Zip Code:11358
Practice Address - Country:US
Practice Address - Phone:917-379-8770
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-07-17
Last Update Date:2012-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist