Provider Demographics
NPI:1144877309
Name:VAZQUEZ, CLARISSA GUADALUPE
Entity type:Individual
Prefix:
First Name:CLARISSA
Middle Name:GUADALUPE
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 1:382 RED CEDAR PL
Mailing Address - Street 2:
Mailing Address - City:PERRIS
Mailing Address - State:CA
Mailing Address - Zip Code:92570-2537
Mailing Address - Country:US
Mailing Address - Phone:951-570-2365
Mailing Address - Fax:
Practice Address - Street 1:382 RED CEDAR PL
Practice Address - Street 2:
Practice Address - City:PERRIS
Practice Address - State:CA
Practice Address - Zip Code:92570-2537
Practice Address - Country:US
Practice Address - Phone:951-570-2365
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-08-22
Last Update Date:2019-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
20020600563900OtherIEHP DIRECT
20020600563900OtherMEDICAL