Healthcare Provider Details

I. General information

NPI: 1891335600
Provider Name (Legal Business Name): YESENIA M VAZQUEZ
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/09/2020
Last Update Date: 02/23/2024
Certification Date: 02/23/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

108 W CITRUS ST
ALTAMONTE SPRINGS FL
32714-2502
US

IV. Provider business mailing address

777 N ORANGE AVE APT 627
ORLANDO FL
32801-1186
US

V. Phone/Fax

Practice location:
  • Phone: 321-972-9215
  • Fax:
Mailing address:
  • Phone: 407-485-1498
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: