Provider Demographics
NPI:1366900979
Name:VASQUEZ, VICTOR R
Entity type:Individual
Prefix:
First Name:VICTOR
Middle Name:R
Last Name:VASQUEZ
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 1:5043 FRANKFORD AVE
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19124-2644
Mailing Address - Country:US
Mailing Address - Phone:215-744-4343
Mailing Address - Fax:215-744-8731
Practice Address - Street 1:5043 FRANKFORD AVE
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19124-2644
Practice Address - Country:US
Practice Address - Phone:215-744-4343
Practice Address - Fax:215-744-8731
Is Sole Proprietor?:Yes
Enumeration Date:2019-03-04
Last Update Date:2019-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health