Healthcare Provider Details

I. General information

NPI: 1851085666
Provider Name (Legal Business Name): ROCIO VACA LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/05/2023
Last Update Date: 06/05/2023
Certification Date: 05/31/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

520 BROADWAY FL 2
SANTA MONICA CA
90401-2420
US

IV. Provider business mailing address

PO BOX 564
YORBA LINDA CA
92885-0564
US

V. Phone/Fax

Practice location:
  • Phone: 323-205-7088
  • Fax:
Mailing address:
  • Phone: 714-485-9226
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number113199
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: