Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 101YM0800X | Mental Health Counselor | 0000000 | MN |
N | 103TC1900X | Counseling Psychologist | 0000000 | MN |
NPI | 1114503711 |
---|---|
Provider Name | Domonic Vasquez |
First Address | Minneapolis, MN 55430-1751 |
Second Address | Minneapolis, MN 55430-1751 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 23/03/2021 |
Last Update Date | 23/03/2021 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
00000000 | (05) | MN |