Healthcare Provider Details

I. General information

NPI: 1063074698
Provider Name (Legal Business Name): DIANA VAZQUEZ DUQUE PHD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/03/2019
Last Update Date: 09/10/2026
Certification Date: 09/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

707 SW GAINES ST
PORTLAND OR
97239-2901
US

IV. Provider business mailing address

707 SW GAINES ST
PORTLAND OR
97239-2901
US

V. Phone/Fax

Practice location:
  • Phone: 503-494-0199
  • Fax: 503-494-6868
Mailing address:
  • Phone: 503-494-0199
  • Fax: 503-494-6868

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: