Healthcare Provider Details

I. General information

NPI: 1114880713
Provider Name (Legal Business Name): AVERY LUIS VAZQUEZ
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/09/2025
Last Update Date: 12/09/2025
Certification Date: 12/09/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

682 PLEASANT DR
WARREN PA
16365-3499
US

IV. Provider business mailing address

119 N SOUTH ST
WARREN PA
16365-2762
US

V. Phone/Fax

Practice location:
  • Phone: 814-723-7060
  • Fax:
Mailing address:
  • Phone: 814-779-8502
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: