Provider Demographics
NPI:1528490760
Name:VAZQUEZ, ISAAC A (CMHC, LMFT)
Entity type:Individual
Prefix:
First Name:ISAAC
Middle Name:A
Last Name:VAZQUEZ
Suffix:
Gender:M
Credentials:CMHC, LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4076 E SOUTH PASS RD
Mailing Address - Street 2:
Mailing Address - City:EAGLE MOUNTAIN
Mailing Address - State:UT
Mailing Address - Zip Code:84005-6049
Mailing Address - Country:US
Mailing Address - Phone:801-341-9521
Mailing Address - Fax:
Practice Address - Street 1:379 N UNIVERSITY AVE STE 300
Practice Address - Street 2:
Practice Address - City:PROVO
Practice Address - State:UT
Practice Address - Zip Code:84601-2878
Practice Address - Country:US
Practice Address - Phone:801-341-9521
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-07-30
Last Update Date:2024-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT11009876-6004101YM0800X, 101YM0800X
UT11009876-3902106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist