Provider Demographics
NPI:1275281743
Name:VEGA, ALEXANDER
Entity Type:Individual
Prefix:
First Name:ALEXANDER
Middle Name:
Last Name:VEGA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:206 N CHARLENE TER
Mailing Address - Street 2:
Mailing Address - City:ANAHEIM
Mailing Address - State:CA
Mailing Address - Zip Code:92806-3037
Mailing Address - Country:US
Mailing Address - Phone:171-434-9953
Mailing Address - Fax:
Practice Address - Street 1:206 N CHARLENE TER
Practice Address - Street 2:
Practice Address - City:ANAHEIM
Practice Address - State:CA
Practice Address - Zip Code:92806-3037
Practice Address - Country:US
Practice Address - Phone:171-434-9953
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-03-14
Last Update Date:2022-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA0000000101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health