Healthcare Provider Details

I. General information

NPI: 1871507475
Provider Name (Legal Business Name): STACY M VASQUEZ LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/28/2006
Last Update Date: 03/17/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2120 RAMROD AVE 1212
HENDERSON NV
89014-2008
US

IV. Provider business mailing address

2120 RAMROD AVE 1212
HENDERSON NV
89014-2008
US

V. Phone/Fax

Practice location:
  • Phone: 702-860-4549
  • Fax:
Mailing address:
  • Phone: 702-860-4549
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number2789-S
License Number StateNV
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberIC-520
License Number StateNV
# 3
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number5763-C
License Number StateNV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: