Provider Demographics
NPI:1134688872
Name:VESAGAS, THERESE KATHRYN
Entity Type:Individual
Prefix:
First Name:THERESE
Middle Name:KATHRYN
Last Name:VESAGAS
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 1:8501 WILSHIRE BLVD STE 336
Mailing Address - Street 2:
Mailing Address - City:BEVERLY HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:90211-3134
Mailing Address - Country:US
Mailing Address - Phone:310-659-9511
Mailing Address - Fax:
Practice Address - Street 1:8501 WILSHIRE BLVD STE 336
Practice Address - Street 2:
Practice Address - City:BEVERLY HILLS
Practice Address - State:CA
Practice Address - Zip Code:90211-3134
Practice Address - Country:US
Practice Address - Phone:310-659-9511
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-12
Last Update Date:2021-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106S00000X
CA20990225X00000X
1-19-35501103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
No103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst