Provider Demographics
NPI:1114276573
Name:MATWIN VAGO, SONIA (PHD)
Entity Type:Individual
Prefix:
First Name:SONIA
Middle Name:
Last Name:MATWIN VAGO
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:SONIA
Other - Middle Name:
Other - Last Name:MATWIN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PHD
Mailing Address - Street 1:1601 23RD AVE S FL 3
Mailing Address - Street 2:VANDERBILT UNIVERSITY MEDICAL CENTER
Mailing Address - City:NASHVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37212-3133
Mailing Address - Country:US
Mailing Address - Phone:615-322-5976
Mailing Address - Fax:
Practice Address - Street 1:1601 23RD AVE S FL 3
Practice Address - Street 2:VANDERBILT UNIVERSITY MEDICAL CENTER
Practice Address - City:NASHVILLE
Practice Address - State:TN
Practice Address - Zip Code:37212-3133
Practice Address - Country:US
Practice Address - Phone:615-322-5976
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-08-31
Last Update Date:2020-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA9972103TC0700X
TN3420103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA110026265EMedicaid