Provider Demographics
NPI:1275727968
Name:VEGA, THERESE M
Entity Type:Individual
Prefix:
First Name:THERESE
Middle Name:M
Last Name:VEGA
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 1:2014 N STUDEBAKER RD
Mailing Address - Street 2:
Mailing Address - City:LONG BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90815-3539
Mailing Address - Country:US
Mailing Address - Phone:562-301-7147
Mailing Address - Fax:
Practice Address - Street 1:5150 E PCH STE 100
Practice Address - Street 2:
Practice Address - City:LONG BEACH
Practice Address - State:CA
Practice Address - Zip Code:90804-3394
Practice Address - Country:US
Practice Address - Phone:562-490-7600
Practice Address - Fax:562-490-7601
Is Sole Proprietor?:No
Enumeration Date:2007-09-05
Last Update Date:2013-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAIMF54455106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist