Provider Demographics
NPI:1013541176
Name:VEGA, SAMUEL III (RBT)
Entity Type:Individual
Prefix:MR
First Name:SAMUEL
Middle Name:
Last Name:VEGA
Suffix:III
Gender:M
Credentials:RBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1155 SW 123RD TER
Mailing Address - Street 2:
Mailing Address - City:PEMBROKE PINES
Mailing Address - State:FL
Mailing Address - Zip Code:33025-5788
Mailing Address - Country:US
Mailing Address - Phone:954-200-3391
Mailing Address - Fax:
Practice Address - Street 1:1750 N UNIVERSITY DR STE 205
Practice Address - Street 2:
Practice Address - City:CORAL SPRINGS
Practice Address - State:FL
Practice Address - Zip Code:33071-6077
Practice Address - Country:US
Practice Address - Phone:954-828-0425
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-02-27
Last Update Date:2020-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician