Healthcare Provider Details

I. General information

NPI: 1215476189
Provider Name (Legal Business Name): MICHELLE VAZQUEZ
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/13/2017
Last Update Date: 05/23/2024
Certification Date: 05/23/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2280 MARKET STREET, SUITE 145
RIVERSIDE CA
92501-0400
US

IV. Provider business mailing address

9836 WHITEWATER RD.
MORENO VALLEY CA
92557
US

V. Phone/Fax

Practice location:
  • Phone: 888-588-8995
  • Fax:
Mailing address:
  • Phone: 909-519-8665
  • Fax: 909-833-2998

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number122781
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: