Provider Demographics
NPI:1174084495
Name:VASQUEZ VILLAGOMEZ, BERENICE (AMFT)
Entity type:Individual
Prefix:
First Name:BERENICE
Middle Name:
Last Name:VASQUEZ VILLAGOMEZ
Suffix:
Gender:F
Credentials:AMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1465 30TH ST STE K
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92154-3497
Mailing Address - Country:US
Mailing Address - Phone:619-428-1000
Mailing Address - Fax:619-428-1091
Practice Address - Street 1:1161 BAY BLVD STE B
Practice Address - Street 2:
Practice Address - City:CHULA VISTA
Practice Address - State:CA
Practice Address - Zip Code:91911-2670
Practice Address - Country:US
Practice Address - Phone:619-585-7686
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-28
Last Update Date:2025-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAMFT123381101Y00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program