Provider Demographics
NPI:1164187779
Name:VARA VARGAS, ROSA ISELA
Entity Type:Individual
Prefix:
First Name:ROSA
Middle Name:ISELA
Last Name:VARA VARGAS
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 1:2611 14TH PL FL 2
Mailing Address - Street 2:
Mailing Address - City:ASTORIA
Mailing Address - State:NY
Mailing Address - Zip Code:11102-3554
Mailing Address - Country:US
Mailing Address - Phone:294-319-2139
Mailing Address - Fax:
Practice Address - Street 1:2611 14TH PL FL 2
Practice Address - Street 2:
Practice Address - City:ASTORIA
Practice Address - State:NY
Practice Address - Zip Code:11102-3554
Practice Address - Country:US
Practice Address - Phone:294-319-2139
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-11-08
Last Update Date:2021-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst