Provider Demographics
NPI:1043915556
Name:VASQUEZ, KELI MARIE (AGENCY AFFILIATED CO)
Entity type:Individual
Prefix:
First Name:KELI
Middle Name:MARIE
Last Name:VASQUEZ
Suffix:
Gender:F
Credentials:AGENCY AFFILIATED CO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 177
Mailing Address - Street 2:
Mailing Address - City:OCEAN PARK
Mailing Address - State:WA
Mailing Address - Zip Code:98640-0177
Mailing Address - Country:US
Mailing Address - Phone:360-214-0474
Mailing Address - Fax:
Practice Address - Street 1:152 1ST AVE N
Practice Address - Street 2:
Practice Address - City:ILWACO
Practice Address - State:WA
Practice Address - Zip Code:98624-9137
Practice Address - Country:US
Practice Address - Phone:360-214-0474
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-04-03
Last Update Date:2024-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACG61420119101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor