Healthcare Provider Details

I. General information

NPI: 1568692911
Provider Name (Legal Business Name): ALICE VASQUEZ M.A.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/20/2009
Last Update Date: 02/28/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3301 E 12TH ST SUITE 259
OAKLAND CA
94601-3424
US

IV. Provider business mailing address

3301 E 12TH ST SUITE 259
OAKLAND CA
94601-3424
US

V. Phone/Fax

Practice location:
  • Phone: 510-368-2051
  • Fax: 510-269-9031
Mailing address:
  • Phone: 510-368-2051
  • Fax: 510-269-9031

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License NumberIMF95027
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License NumberIMF95027
License Number StateCA
# 3
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License NumberIMF95027
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: