Provider Demographics
NPI:1417676255
Name:VAZQUEZ, KATIE LYNN (CPSS)
Entity type:Individual
Prefix:
First Name:KATIE
Middle Name:LYNN
Last Name:VAZQUEZ
Suffix:
Gender:F
Credentials:CPSS
Other - Prefix:
Other - First Name:KATIE
Other - Middle Name:LYNN
Other - Last Name:NYE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1260 W BLAINE ST APT 13
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92507-3699
Mailing Address - Country:US
Mailing Address - Phone:951-452-2544
Mailing Address - Fax:
Practice Address - Street 1:2085 RUSTIN AVE
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92507-2498
Practice Address - Country:US
Practice Address - Phone:951-955-7163
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-08-24
Last Update Date:2023-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CABKITYVZOJMUFESPN175T00000X
CA106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician