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General NPI Number Information
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NPI Number | 1124634209
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Entity Type | Individual
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Provider Name | ASHLEY JAILYN VAZQUEZ MATIAS PSYD
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Gender | Female
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Dates
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Enumeration Date | 09/23/2020
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Last Update Date | 09/23/2020
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Provider Practice Location Address
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Address Line | CARR. 115 KM 19.2 INT
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City | AGUADA
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State | PR
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Zip | 00602
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Country | US
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Telephone | 787-667-3553
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Fax |
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Provider Business Mailing Address
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Address Line | HC 57 BOX 9400
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City | AGUADA
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State | PR
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Zip | 00602-9828
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Country | US
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Telephone | 787-667-3553
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103TC0700X
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Taxonomy Name | Clinical Psychologist
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License Number | 6714
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License Number State | PR
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