Provider Demographics
NPI:1225222557
Name:VEGA, DESIREE EILEEN MIRANDA (MFT)
Entity Type:Individual
Prefix:
First Name:DESIREE
Middle Name:EILEEN MIRANDA
Last Name:VEGA
Suffix:
Gender:F
Credentials:MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1662 FREMONT AVE
Mailing Address - Street 2:
Mailing Address - City:SIMI VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:93065-4524
Mailing Address - Country:US
Mailing Address - Phone:818-427-3891
Mailing Address - Fax:818-855-7428
Practice Address - Street 1:11145 TAMPA AVE STE 15A
Practice Address - Street 2:
Practice Address - City:NORTHRIDGE
Practice Address - State:CA
Practice Address - Zip Code:91326
Practice Address - Country:US
Practice Address - Phone:818-427-3891
Practice Address - Fax:818-855-7428
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-29
Last Update Date:2018-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAIMF50330106H00000X
CA50330106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist