Healthcare Provider Details

I. General information

NPI: 1508541012
Provider Name (Legal Business Name): ARLENE ROSARIO VAZQUEZ RADT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/21/2023
Last Update Date: 06/21/2023
Certification Date: 06/21/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5178 ATLANTIC AVE
LONG BEACH CA
90805-6510
US

IV. Provider business mailing address

6022 VARIEL AVE
WOODLAND HILLS CA
91367-3719
US

V. Phone/Fax

Practice location:
  • Phone: 818-996-1051
  • Fax:
Mailing address:
  • Phone: 818-996-1051
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberR1507980523
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: