Provider Demographics
NPI:1538739032
Name:VAZQUEZ, ODALYS (LCDA)
Entity type:Individual
Prefix:
First Name:ODALYS
Middle Name:
Last Name:VAZQUEZ
Suffix:
Gender:F
Credentials:LCDA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 917
Mailing Address - Street 2:
Mailing Address - City:COROZAL
Mailing Address - State:PR
Mailing Address - Zip Code:00783-0917
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:CARR. 159 KM 13.2 COROZAL SHOPPING VILLAGE SEGUNDA PLA
Practice Address - Street 2:LOCAL 17-A URB. LOMA LINDA
Practice Address - City:COROZAL
Practice Address - State:PR
Practice Address - Zip Code:00783
Practice Address - Country:US
Practice Address - Phone:787-503-9053
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-28
Last Update Date:2021-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR5174103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounselingGroup - Single Specialty