=====================================================
General NPI Number Information
=====================================================
NPI Number | 1396235974
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MRS. MAYRA ELIZABETH VASQUEZ
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/18/2018
-----------------------------------------------------
Last Update Date | 05/18/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4898 E IRLO BRONSON MEMORIAL HWY
-----------------------------------------------------
City | SAINT CLOUD
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34771-8714
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 407-891-3091
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4113 WELLINGTON WOODS CIR APT 107
-----------------------------------------------------
City | KISSIMMEE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34741-2747
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 407-569-5473
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 104100000X
-----------------------------------------------------
Taxonomy Name | Social Worker
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------