Provider Demographics
NPI:1528782844
Name:VAZQUEZ, ERNESTO
Entity type:Individual
Prefix:
First Name:ERNESTO
Middle Name:
Last Name:VAZQUEZ
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2555 ROOSEVELT BLVD APT 5
Mailing Address - Street 2:
Mailing Address - City:EUGENE
Mailing Address - State:OR
Mailing Address - Zip Code:97402-2549
Mailing Address - Country:US
Mailing Address - Phone:541-279-4651
Mailing Address - Fax:
Practice Address - Street 1:1144 GATEWAY LOOP STE 200
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:OR
Practice Address - Zip Code:97477-7706
Practice Address - Country:US
Practice Address - Phone:541-279-4651
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-09-29
Last Update Date:2023-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR101YA0400X101YA0400X
106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician