Provider Demographics
NPI:1336500495
Name:VEGA, VICTORIA ROSE (MS, CCC-SLP)
Entity Type:Individual
Prefix:
First Name:VICTORIA
Middle Name:ROSE
Last Name:VEGA
Suffix:
Gender:F
Credentials:MS, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:77 MONITOR ST APT 3R
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11222-4734
Mailing Address - Country:US
Mailing Address - Phone:616-528-2125
Mailing Address - Fax:
Practice Address - Street 1:77 MONITOR ST APT 3R
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11222-4734
Practice Address - Country:US
Practice Address - Phone:616-528-2125
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-03-16
Last Update Date:2019-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASL012887235Z00000X
NY028773235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist