Basic Information
| Provider Information | |||||||||
| NPI: | 1215476189 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | VAZQUEZ | ||||||||
| FirstName: | MICHELLE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 9836 WHITEWATER RD. | ||||||||
| Address2: | |||||||||
| City: | MORENO VALLEY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 92557 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9095198665 | ||||||||
| FaxNumber: | 9098332998 | ||||||||
| Practice Location | |||||||||
| Address1: | 233 WEST BASELINE ROAD | ||||||||
| Address2: | |||||||||
| City: | LA VERNE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 917500400 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9098332986 | ||||||||
| FaxNumber: | 9095963567 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/13/2017 | ||||||||
| LastUpdateDate: | 05/12/2017 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106H00000X | Y | Behavioral Health & Social Service Providers | Marriage & Family Therapist |
No ID Information.