Basic Information
| Provider Information | |||||||||
| NPI: | 1417615527 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | VAZQUEZ | ||||||||
| FirstName: | KELLIE | ||||||||
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| Credential: | CMA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7440 W MARGINAL WAY S | ||||||||
| Address2: | |||||||||
| City: | SEATTLE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 981084141 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 1302 W GARDNER AVE | ||||||||
| Address2: | |||||||||
| City: | SPOKANE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 992012059 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5095036010 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 12/06/2021 | ||||||||
| LastUpdateDate: | 12/07/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 12/07/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | N | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | 363A00000X | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.