Provider Demographics
NPI:1043885296
Name:VEGA, AMANDA GRACE
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:GRACE
Last Name:VEGA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2701 N 16TH ST STE 316
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85006-1266
Mailing Address - Country:US
Mailing Address - Phone:602-650-1212
Mailing Address - Fax:
Practice Address - Street 1:1850 COPPER LOOP
Practice Address - Street 2:
Practice Address - City:LAS CRUCES
Practice Address - State:NM
Practice Address - Zip Code:88005-8139
Practice Address - Country:US
Practice Address - Phone:575-449-8159
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-05-20
Last Update Date:2021-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor