MEDICARE: IMELDA VASQUEZ LPS

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	101YM0800X	Mental Health Counselor	74344	TX

General Provider Information

NPI Number	:	1699285460
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	IMELDA VASQUEZ LPS

Provider Business Mailing Address
First Line	:	6363 DEZAVALA ROAD
Second Line	:
City	:	SAN ANTONIO
State	:	TX
Zip	:	78249
Country	:	US
Telephone Number	:	210-399-4838
Fax Number	:	210-877-9279

Provider Business Practice Location Address
First Line	:	6363 DEZAVALA ROAD
Second Line	:
City	:	SAN ANTONIO
State	:	TX
Zip	:	78249
Country	:	US
Telephone Number	:	210-399-4838
Fax Number	:	210-877-9279

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

Provider Enumeration Date	:	10/06/2017
Last Update Date	:	10/06/2017

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