Provider Demographics
NPI:1497102461
Name:VEGA, SELENE (LMFT)
Entity Type:Individual
Prefix:DR
First Name:SELENE
Middle Name:
Last Name:VEGA
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1691
Mailing Address - Street 2:
Mailing Address - City:SANTA CRUZ
Mailing Address - State:CA
Mailing Address - Zip Code:95061-1691
Mailing Address - Country:US
Mailing Address - Phone:831-234-7823
Mailing Address - Fax:
Practice Address - Street 1:200 WOODLANDER PL
Practice Address - Street 2:
Practice Address - City:SCOTTS VALLEY
Practice Address - State:CA
Practice Address - Zip Code:95066-2624
Practice Address - Country:US
Practice Address - Phone:831-234-7823
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-05-19
Last Update Date:2016-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC 32604106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist