Healthcare Provider Details

I. General information

NPI: 1902065576
Provider Name (Legal Business Name): LORI J VASQUEZ
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/08/2008
Last Update Date: 06/08/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3505 LONG BEACH BLVD STE 1F
LONG BEACH CA
90807-3946
US

IV. Provider business mailing address

738 MAIN ST UNIT 302
EL SEGUNDO CA
90245-3045
US

V. Phone/Fax

Practice location:
  • Phone: 562-988-3436
  • Fax:
Mailing address:
  • Phone: 562-988-3436
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: