MEDICARE: ELIEZER VAZQUEZ LCSW

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker	C005393	NC

General Provider Information

NPI Number	:	1114077195
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ELIEZER VAZQUEZ LCSW

Provider Business Mailing Address
First Line	:	3125 POPLARWOOD CT
Second Line	:	SUITE 203
City	:	RALEIGH
State	:	NC
Zip	:	27604-1084
Country	:	US
Telephone Number	:	919-872-7373
Fax Number	:	919-872-3713

Provider Business Practice Location Address
First Line	:	2809 HIGHWOODS BLVD
Second Line	:	SUITE 103
City	:	RALEIGH
State	:	NC
Zip	:	27604-1000
Country	:	US
Telephone Number	:	919-872-7373
Fax Number	:	919-872-3713

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/11/2007
Last Update Date	:	07/08/2007

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