Provider Demographics
NPI:1962988311
Name:VASQUEZ, MARISSA KATRINA
Entity type:Individual
Prefix:
First Name:MARISSA
Middle Name:KATRINA
Last Name:VASQUEZ
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 1:1812 FLEMING ST
Mailing Address - Street 2:
Mailing Address - City:POMONA
Mailing Address - State:CA
Mailing Address - Zip Code:91766-1027
Mailing Address - Country:US
Mailing Address - Phone:909-313-8932
Mailing Address - Fax:
Practice Address - Street 1:1812 FLEMING ST
Practice Address - Street 2:
Practice Address - City:POMONA
Practice Address - State:CA
Practice Address - Zip Code:91766-1027
Practice Address - Country:US
Practice Address - Phone:909-313-8932
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-18
Last Update Date:2018-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)