Provider Demographics
NPI:1376240838
Name:VEGA, MIDALIS DAMAYANTI
Entity Type:Individual
Prefix:
First Name:MIDALIS
Middle Name:DAMAYANTI
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 1:8895 NW 112TH TER
Mailing Address - Street 2:
Mailing Address - City:HIALEAH GARDENS
Mailing Address - State:FL
Mailing Address - Zip Code:33018-4533
Mailing Address - Country:US
Mailing Address - Phone:786-281-7139
Mailing Address - Fax:
Practice Address - Street 1:657 SOUTH DR STE 403
Practice Address - Street 2:
Practice Address - City:MIAMI SPRINGS
Practice Address - State:FL
Practice Address - Zip Code:33166-5926
Practice Address - Country:US
Practice Address - Phone:786-860-5161
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-02-14
Last Update Date:2023-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician