Healthcare Provider Details

I. General information

NPI: 1083974497
Provider Name (Legal Business Name): CHRISTINE DE LA PAZ VASQUEZ
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/18/2012
Last Update Date: 06/28/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10776 FREMONT ST
YUCAIPA CA
92399
US

IV. Provider business mailing address

10776 FREMONT ST
YUCAIPA CA
92399-9630
US

V. Phone/Fax

Practice location:
  • Phone: 909-797-0114
  • Fax:
Mailing address:
  • Phone: 909-797-0114
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberASW37032
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: