Provider Demographics
NPI:1730719337
Name:VASQUEZ, JUAN ELIAS (AUD)
Entity type:Individual
Prefix:
First Name:JUAN
Middle Name:ELIAS
Last Name:VASQUEZ
Suffix:
Gender:M
Credentials:AUD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:920 W CULLOM AVE PH UNIT
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60613-1632
Mailing Address - Country:US
Mailing Address - Phone:909-992-9660
Mailing Address - Fax:
Practice Address - Street 1:920 W CULLOM AVE PH UNIT
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60613-1632
Practice Address - Country:US
Practice Address - Phone:909-992-9660
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-01-22
Last Update Date:2020-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL147.001756231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist