Provider Demographics
NPI:1164136115
Name:VASQUEZ, MANUEL JOHN
Entity type:Individual
Prefix:
First Name:MANUEL
Middle Name:JOHN
Last Name:VASQUEZ
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2772 S. MARTIN LUTHER KING BVLD
Mailing Address - Street 2:2772 S. MARTIN LUTHER KING BVLD
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93706-3056
Mailing Address - Country:US
Mailing Address - Phone:559-265-4800
Mailing Address - Fax:
Practice Address - Street 1:12772 S. MARTIN LUTHER KING BVLD
Practice Address - Street 2:12772 S. MARTIN LUTHER KING BVLD
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93721-1808
Practice Address - Country:US
Practice Address - Phone:559-264-2700
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-01-12
Last Update Date:2025-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA17186101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)