Healthcare Provider Details

I. General information

NPI: 1255179867
Provider Name (Legal Business Name): STEPHANIE J VAZQUEZ
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/17/2024
Last Update Date: 08/25/2026
Certification Date: 08/25/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1539 MCHENRY AVE
MODESTO CA
95350-4528
US

IV. Provider business mailing address

1539 MCHENRY AVE STE A
MODESTO CA
95350-4528
US

V. Phone/Fax

Practice location:
  • Phone: 209-758-0825
  • Fax:
Mailing address:
  • Phone: 209-702-0139
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number135739
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: