Provider Demographics
NPI:1255480596
Name:VARGAS, MARIELA (PSYD)
Entity Type:Individual
Prefix:
First Name:MARIELA
Middle Name:
Last Name:VARGAS
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:110 CEDAR STREET
Mailing Address - Street 2:SUITE 10
Mailing Address - City:WELLESLEY
Mailing Address - State:MA
Mailing Address - Zip Code:02481-5323
Mailing Address - Country:US
Mailing Address - Phone:617-902-8393
Mailing Address - Fax:
Practice Address - Street 1:110 CEDAR STREET
Practice Address - Street 2:SUITE 10
Practice Address - City:WELLESLEY
Practice Address - State:MA
Practice Address - Zip Code:02481-5323
Practice Address - Country:US
Practice Address - Phone:617-902-8393
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-09
Last Update Date:2017-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA7783103G00000X
MA1123103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAW06397OtherBLUE CROSS PROVIDER #