Provider Demographics
NPI:1275192437
Name:VEGA, MARIO J (RBT)
Entity Type:Individual
Prefix:
First Name:MARIO
Middle Name:J
Last Name:VEGA
Suffix:
Gender:M
Credentials:RBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 SPENRYN DR
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:AL
Mailing Address - Zip Code:35758-1890
Mailing Address - Country:US
Mailing Address - Phone:256-772-4400
Mailing Address - Fax:
Practice Address - Street 1:100 SPENRYN DR
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:AL
Practice Address - Zip Code:35758-1890
Practice Address - Country:US
Practice Address - Phone:256-772-4400
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-06-11
Last Update Date:2019-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL18-49403106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician