Provider Demographics
NPI:1437818903
Name:VEGA, VERONICA DIEDRA
Entity Type:Individual
Prefix:
First Name:VERONICA
Middle Name:DIEDRA
Last Name:VEGA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:VERONICA
Other - Middle Name:
Other - Last Name:NOGUERA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LMFT
Mailing Address - Street 1:4107 W SPRUCE ST STE 100
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33607-2346
Mailing Address - Country:US
Mailing Address - Phone:813-636-8811
Mailing Address - Fax:813-636-8855
Practice Address - Street 1:4107 W SPRUCE ST STE 100
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33607-2346
Practice Address - Country:US
Practice Address - Phone:813-636-8811
Practice Address - Fax:813-636-8855
Is Sole Proprietor?:Yes
Enumeration Date:2021-12-13
Last Update Date:2022-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
FLMT4208106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL113045000Medicaid