Healthcare Provider Details

I. General information

NPI: 1285449207
Provider Name (Legal Business Name): ETHAN AARON VACA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/07/2025
Last Update Date: 02/07/2025
Certification Date: 02/06/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

510 S VERMONT AVE
LOS ANGELES CA
90020-1912
US

IV. Provider business mailing address

510 S VERMONT AVE
LOS ANGELES CA
90020-1912
US

V. Phone/Fax

Practice location:
  • Phone: 800-854-7771
  • Fax:
Mailing address:
  • Phone: 951-541-8843
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberASW122313
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: