Provider Demographics
NPI:1124577069
Name:VEGA BURGOS, JOAMELY
Entity Type:Individual
Prefix:
First Name:JOAMELY
Middle Name:
Last Name:VEGA BURGOS
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 1:120 MAPLE ST
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MA
Mailing Address - Zip Code:01103-2203
Mailing Address - Country:US
Mailing Address - Phone:413-846-0445
Mailing Address - Fax:
Practice Address - Street 1:120 MAPLE ST
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MA
Practice Address - Zip Code:01103-2203
Practice Address - Country:US
Practice Address - Phone:413-846-0445
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-10-03
Last Update Date:2016-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAM18463OtherBLUE CROSS BLUE SHIELD
MA1307576Medicaid
MA1303295Medicaid
MA1307576Medicaid