Provider Demographics
NPI:1043808009
Name:VAZQUEZ, KARLA
Entity type:Individual
Prefix:
First Name:KARLA
Middle Name:
Last Name:VAZQUEZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:904 MISSION RIDGE DR
Mailing Address - Street 2:
Mailing Address - City:MANTECA
Mailing Address - State:CA
Mailing Address - Zip Code:95337-8011
Mailing Address - Country:US
Mailing Address - Phone:209-665-6871
Mailing Address - Fax:
Practice Address - Street 1:904 MISSION RIDGE DR
Practice Address - Street 2:
Practice Address - City:MANTECA
Practice Address - State:CA
Practice Address - Zip Code:95337-8011
Practice Address - Country:US
Practice Address - Phone:209-665-6871
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-05
Last Update Date:2021-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA200124229Medicaid