Provider Demographics
NPI:1295398949
Name:VEGA, LYSANDRA
Entity Type:Individual
Prefix:
First Name:LYSANDRA
Middle Name:
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 1:960 BIRCHWOOD LN
Mailing Address - Street 2:
Mailing Address - City:NISKAYUNA
Mailing Address - State:NY
Mailing Address - Zip Code:12309-3116
Mailing Address - Country:US
Mailing Address - Phone:518-836-4442
Mailing Address - Fax:
Practice Address - Street 1:45 DELAWARE AVE
Practice Address - Street 2:
Practice Address - City:ALBANY
Practice Address - State:NY
Practice Address - Zip Code:12202-1301
Practice Address - Country:US
Practice Address - Phone:518-475-6496
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-04-18
Last Update Date:2019-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY09650411041S0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041S0200XBehavioral Health & Social Service ProvidersSocial WorkerSchool