Healthcare Provider Details

I. General information

NPI: 1528782844
Provider Name (Legal Business Name): ERNESTO VAZQUEZ CADC II, QMHA I, RBT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: ERNESTO VAZQUEZ FALCON

II. Dates (important events)

Enumeration Date: 09/29/2022
Last Update Date: 06/24/2026
Certification Date: 06/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 SERENITY LN
COBURG OR
97408-9350
US

IV. Provider business mailing address

1 SERENITY LN
COBURG OR
97408-9350
US

V. Phone/Fax

Practice location:
  • Phone: 541-687-1110
  • Fax:
Mailing address:
  • Phone: 541-687-1110
  • Fax: 541-683-9061

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License NumberIN-10227061
License Number StateOR
# 2
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number101YA0400X
License Number StateOR
# 3
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number24-QMHA-I-00436
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: