Healthcare Provider Details

I. General information

NPI: 1710677356
Provider Name (Legal Business Name): KELLIE MARIE VASQUEZ MSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/08/2023
Last Update Date: 05/08/2023
Certification Date: 05/08/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2275 S MAIN ST STE 201
CORONA CA
92882-5303
US

IV. Provider business mailing address

3355 N WHITE AVENUE PO BOX #713
LA VERNE CA
91750
US

V. Phone/Fax

Practice location:
  • Phone: 951-279-3222
  • Fax: 951-279-5222
Mailing address:
  • Phone: 626-244-7748
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: