Healthcare Provider Details

I. General information

NPI: 1194161794
Provider Name (Legal Business Name): LEO ANTHONY VASQUEZ BSW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/22/2013
Last Update Date: 11/21/2022
Certification Date: 11/21/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3400 WATT AVE SUITE #206
SACRAMENTO CA
95821-3602
US

IV. Provider business mailing address

3400 WATT AVE SUITE #206
SACRAMENTO CA
95821-3602
US

V. Phone/Fax

Practice location:
  • Phone: 916-821-9090
  • Fax:
Mailing address:
  • Phone: 916-993-4131
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: